TRENDWATCH: Hospital and Health System Workforce Strategic Planning AMERICAN HOSPITAL ASSOCIATION | JANUARY 2020 TRENDWATCH HOSPITAL AND HEALTH SYSTEM WORKFORCE STRATEGIC PLANNING ©2020 American Hospital Association | January 2020 Page 1 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning TRENDWATCH: Hospital and Health System Workforce Strategic Planning America’s hospitals and health systems are at the strategic discussion and planning within hospitals and center of their communities, both as providers of among communities they serve. critical services and as large – and often the largest – employers. They train tomorrow’s health care providers A National Snapshot of the Hospital and cultivate future leaders by building and expanding their dynamic workforces to effectively keep pace with Workforce health care trends, evolving technology and broader In 2018, America’s hospitals and health systems socio-cultural trends. treated 143 million people in emergency departments, provided 623 million outpatient visits, performed over Across health care, job openings are at record highs. 28 million surgeries and delivered nearly 4 million Using Bureau of Labor Statistics (BLS) data, Forbes babies.2 Every year, hospitals provide vital health care estimated that in December 2018 there were "over 1.2 services to hundreds of millions of people. However, million health care jobs open … a 17.9% increase year the importance of hospitals to their communities over year.”1 This TrendWatch is intended to highlight extends far beyond the health care services they emerging trends in workforce, as well as outline key provide. Hospitals and health systems fulfill a critical strategies and tools to embrace new opportunities and role within their communities and across the broader address challenges. Although there are challenges, U.S. economy. there also are opportunities to improve care, motivate and re-skill staff, and modernize processes and business models that reflect the shift toward providing Figure 1: Impact of Community Hospitals on U.S. the right care, at the right time, in the right setting. Economy (Billions), 2018 Impact of Wages and Salaries The workforce trends discussed in this paper fall within six broad categories: professional shortages; $475 financial pressures; burnout; workplace violence; the $667 evolving workforce; and diversity. These categories were identified based on input from hospital and health $1,143 system leaders and are consistent with themes that Impact of Expenditures on the Economy emerged from a targeted literature review. $1,010 Labor is the largest single cost for most hospitals, and $2,313 the workforce is essential to the critical mission of providing life-saving care. While workforce challenges $3,323 are formidable, so are the tools available to hospitals ■ Direct Jobs ■ Ripple Effect ■ Total Jobs and health systems. Each section of this paper includes Source: AHA analysis using BEA RIMS-II (2012/2017) multipliers for hospital NAICS Code a discussion of strategies hospitals are using to convert 622000, released Oct. 2019, applied to American Hospital Association Annual Survey data for 2018. Hospital jobs are total part time and full time jobs. The percent of total challenges into opportunities. employment supported by direct and indirect hospital employment is based on 2018 BLS data -- Total employment in column E is from BLS Table 4 Aug. 2019: Employees on nonfarm payrolls by state and selected industry sector, not seasonally adjusted. Note: This TrendWatch is not intended to be an exhaustive Multipliers released in 2010 and subsequent years no longer include the national level multipliers needed for this chart. catalogue of all workforce-related issues. Instead, it summarizes key trends and can be used to foster ©2020 American Hospital Association | January 2020 Page 2 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Practitioners and technicians make up the vast majority Figure 2: Impact of Community Hospitals on U.S. of the hospital workforce, accounting for roughly 3.4 Jobs (Millions), 2018 million employees with another 800,000 in health care support professions (such as certified nurse assistants). 6.2 In contrast, 700,000 hospital employees are in office $11.1 11.2 and administrative support positions, 200,000 are in management and 100,000 are in business/finance $17.3 17.3 positions.5 (Figure 4) ■ Direct Jobs ■ Ripple Effect ■ Total Jobs Source: AHA analysis using BEA RIMS-II (2012/2017) multipliers for hospital NAICS Code Although total hospital employment has grown in 622000, released Oct. 2019, applied to American Hospital Association Annual Survey data for 2018. Hospital jobs are total part time and full time jobs. The percent of total recent years, it has remained stable relative to overall employment supported by direct and indirect hospital employment is based on 2018 BLS data -- Total employment in column E is from BLS Table 4 Aug. 2019: Employees on utilization. However, the share of certain employees nonfarm payrolls by state and selected industry sector, not seasonally adjusted. Note: Multipliers released in 2010 and subsequent years no longer include the national level engaged in direct patient care has grown. For example, multipliers needed for this chart. the number of full-time equivalent hospital employees per thousand adjusted admissions remained stable from 2009 to 2018, while the number of full-time equivalent Hospitals are significant national employers – more than registered nurses per thousand adjusted admissions 6 million individuals work for hospitals in full- or part- increased from 19.4 to 21.3.6 (Figures 5 and 6) time positions. Hospitals also purchase $1,010 billion in goods and services from other businesses per year, creating economic value for the community. In fact, Figure 3: Percent of Costs in the Inpatient with these ripple effects included, each hospital job Prospective Payment System Hospital Market supports almost two additional jobs, and every dollar Basket, 2018 spent by a hospital supports roughly $2.30 of additional business activity in the economy. Overall, hospitals Wages and Salaries: 55.8% support 17.3 million jobs, or one out of nine jobs, and $3.2 trillion in economic activity.3 (Figures 1 and 2) Delivering high-quality care to communities across the country requires hospitals to assemble a qualified and Drugs: 5.9% skilled workforce, by far the largest cost in hospital patient care. Wages and salaries comprise 56% of Other Products: 11.5% the inpatient prospective payment system hospital market basket, with all other services, drugs and other Other Services: 26.9% medical products collectively accounting for only 44% of inpatient costs.4 (Figure 3) The hospital workforce is relatively high earning, but not All Other: Labor Professional Fees: 11.9% Utilities: Intensive: 5.7% 2.5% overwhelmingly so, averaging roughly $1,200 in weekly pay vs. roughly $900 for other service industries. The All Other: Non-labor Professional Liability Intensive: 5.6% Insurance: 1.2% higher-than-average weekly pay reflects the varying Source: AHA analysis of Centers for Medicare and Medicaid Services data, using base levels of specialized training and/or education required year 2014 weights. (1) Does not include capital. (2) Includes postage and telephone expenses. Note: FY 2017 IPPS Rule uses base year 2014 IPPS Market Basket weights. across roles. Base year 2014 Inpatient Prospective Payment System Market Basket weights do not incorporate impact of prescription drug price growth after the measurement period. ©2020 American Hospital Association | January 2020 Page 3 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Professional Shortages professions. These shortages can strain a hospital’s care delivery and finances, aggravate other workforce A skilled and robust workforce is essential to the challenges such as burnout, and lead to costly delivery of high-quality care. A major obstacle to mitigations. According to BLS, the health care sector building and nurturing a talented and dedicated added 391,000 jobs from March 2018 to May 2019, but workforce is the shortages in many key health care these additions have not alleviated the need for more qualified individuals.7 Figure 4: Hospital Employment by Occupation Type (Thousands), 2017 Health Care Practitioner and Technical: 3,361 Health Care Support: 755 Office and Administrative Support: 738 Other Occupations: 318 Management: 219 Building and Grounds, Cleaning and Maintenance: 190 Community and Social Service: 152 Food Preparation and Serving: 135 Business and Financial Operations: 130 Installation, Maintenance and Repair: 54 Source: Department of Labor, BLS, National Industry-Specific Occupational Employment and Wage Estimates. Data released May 2018. www.bls.gov/oes/current/naics3_622000.htm (1) Does not include public hospitals. Figure 5: Full-time Equivalent Employees per Figure 6: Number of RN FTEs and RN FTEs per Thousands of Adjusted Admissions, 2009-2018 Thousands of Adjusted Admission, 2009-2018 70 25 60 20 50 15 40 30 10 20 5 10 0 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Source: Analysis of American Hospital Association Annual Survey data, 2018, for Source: Analysis of American Hospital Association Annual Survey data, 2018, for community hospitals. (1) RN: Registered Nurse; FTE: Full-time Equivalent. (2) An community hospitals. (1) An aggregate measure of workload reflecting the number of aggregate measure of workload reflecting the number of inpatient admissions, plus inpatient admissions, plus an estimate of the volume of outpatient services, expressed an estimate of the volume of outpatient services, expressed in units equivalent to an in units equivalent to an inpatient admission in terms of level of effort. inpatient admission in terms of level of effort. ©2020 American Hospital Association | January 2020 Page 4 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Nurses: The U.S. needs more than 200,000 new The Health Resources and Services registered nurses (RNs) each year to meet increasing Administration has designated 7,026 American health care needs and to replace nurses entering communities as primary care Health Professional retirement.12 In 2017, more than half of all nurses Shortage Areas. HRSA’s designation, when were age 50 or older, and almost 30% were age 60 or applied to U.S. population data by the Kaiser over. (Figure 9) Efforts over the last two decades have Family Foundation, suggests that nearly 80 resulted in more than 1 million new nurses; however, million Americans live in HPSAs. Nearly 15,000 roughly 2 million new nurses over the next decade are practitioners would be needed in these HPSAs to needed to keep pace with health care demand under fully remedy the shortage. (Figure 7) the current care delivery structure. The American Source: Kaiser Family Foundation. “Primary Care Health Professional Shortage Areas (HPSAs),” kff.org, Dec. 31, 2018. Association of Colleges of Nursing projects that the RN workforce will increase by only half a million nurses between 2016 and 2026, which is just 25% of the Health care workforce shortages vary across projected need.13 professions and have disparate geographic impacts. Hospitals are deploying tools, outlined below, to In interviews with hospital leaders, it was noted that overcome the challenges created by shortages. there has been an increasing scarcity of nurses (as well as APPs) over the last decade, particularly since the Physicians: A recent study from the Association of recession of 2007-2009, and that other opportunities American Medical Colleges (AAMC) projects a national are reducing the number and supply of bedside nurses. shortage of 122,000 physicians by 2032, including Several interviewees observed that many nurses are shortages of primary care physicians and specialists, returning to school to continue their education as nurse such as pathologists, neurologists, radiologists and practitioners, in some cases with support from tuition psychiatrists.8 The physician shortages are exacerbated reimbursement programs from their employers. Some by the uneven geographic distribution of physicians, recent nursing graduates pursue the APP track after which creates challenges for hospitals.9,10 A study of only a short time practicing as RNs. The growth in primary care physicians in California notes that the care management and administrative opportunities for state is facing an imminent shortage of primary care nurses also impact the supply of bedside nurses.14 clinicians – demand is projected to increase from 12% to 18% between 2016 and 2030. This is in part due to the aging of the physician workforce (Figure 8), but also Figure 7: Health Professional Shortage Areas: a cap on the number of Medicare-funded residency Primary Care, by County, 2017 slots, which have been frozen at 1996 levels since the 1997 Balanced Budget Act. The study’s authors further note that the impact of physician shortages will disproportionately affect lower-income and minority populations.11 Beyond California, evolving patterns of care create opportunities for hospitals to adjust staffing and recruitment practices to meet their communities’ needs. As discussed elsewhere in this paper, solutions may include increasing the number of Medicare- funded residency positions, as well as the increased use of advanced practice providers (APPs), particularly Portion of County That Is Shortage Area: ■ None ■ Part ■ Whole in primary care to better meet the care needs of the Source: data.HRSA.gov, 2017. community by increasing access to practitioners. ©2020 American Hospital Association | January 2020 Page 5 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Information Technology and Analysts: Hospitals are Figure 8: Number of Physicians by Age, 2010, 2012, quickly growing their IT and analytics capabilities, a 2014 and 2016 trend expected to continue as the federal government 500 pushes for interoperability, expands risk- and value- 450 based care models, and addresses the field's 400 commitment to data-driven quality of care. Hospitals Number of Physicians (Thousands) 350 may not be using analysts and IT professionals to their 300 full potential, as one interviewee shared, because 250 clinician executives are not always steeped in those 200 skills or content. Analysts and IT professionals are in 150 high demand across industries, and several hospital interviewees expressed concern about recruitment 100 and retention of this skillset. One hospital traditionally 50 filled IT roles with foreign workers but has been limited 2010 2012 2014 2016 by new immigration policies, including the reduced number of approved visas. Analysts are in high demand ■ Under 30 ■ 30-39 ■ 40-49 ■ 50-59 ■ 60-69 ■ 70+ Source: Federation of State Medical Boards (FSMB). 2016 FSMB Census of Licensed by other industries and large technology firms that offer Physicians. (1) Includes actively licensed physicians. Resident physician licenses were higher salaries for similar roles. One interviewee shared excluded when such licensed could be identified. that they must compete for staff with tech giants like Amazon and Microsoft. Behavioral Health Professionals: Across health care, job openings are at record highs, with behavioral health Office Professionals: Hospitals employ large numbers as one area of particular need. The National Council of office professionals, including specialists in finance, for Behavioral Health, using HRSA data, projects the medical records/billing and compliance. The fastest demand for addiction counselors to “increase anywhere growing of these white-collar professions is medical between 21% to 38% by 2030.” Projections are similar records and billing – which is projected to grow 13% by for a number of other behavioral health professions.15 2026.19 High administrative burden from health insurer Other Technicians and Practitioners: Workforce pressures exist across a variety of professions – Figure 9: Percent Distribution of RN Workforce including certified nursing assistants (CNAs), medical by Age Group, 2017 assistants and several technician positions that 20s: 9.7% provide routine patient care and assist higher-skilled 30s: 19.4% professionals. According to one recent survey, the annual turnover rate of hospital CNAs was 27.7% 40s: 20.3% (nearly double the turnover rate of nurses and physician assistants).16 Meanwhile, the aging society will, 50s: 22.6% according to BLS, create a need for 11% more CNAs by 2025.17 The lack of laboratory technicians may be particularly acute – a 2017 survey conducted by 60s and Older: 28.1% the American Society for Clinical Laboratory Science concluded that there were, nationally, 7.2% lab Source: National Council of State Boards of Nursing. National Nursing Workforce Study 2017 technician positions unfilled.18 ©2020 American Hospital Association | January 2020 Page 6 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning denials and prior authorization drive this need (86% of surveyed physicians described the administrative Figure 10: Meeting the Need for Primary Care burden of prior authorization as “high or extremely Health Professionals high,” and 88% said the burden has risen in the last five years).20 Other Professionals: Blue-collar service workers – such as food service, environmental services and landscaping – play an important role in hospital operations. Hospitals experience high turnover among non-degree, (generally) hourly wage employees who may leave for pay increases and more favorable hours in other fields. Compounding this trend is a continued strong U.S. economy that could create shortages in many of these areas. For example, BLS projects that AS GU MP VI PR the need for environmental services will grow 10% by 17 44 13 28 554 2026 across all sectors.21 Percent of Need Met: ■ 1-30.9% ■ 31-40.9% ■ 41-50.9% Geographic Shortages: The distribution of health care ■ 51-60.9% ■ 61-70.9% ■ 71-80.9% professionals across the U.S. is very uneven. The rate Note: Number displayed in state represents the number of practitioners needed in HPSAs to remove the shortage designation. Source: HRSA Bureau of Health Workforce, of clinicians per 100,000 state residents ranges from June 30, 2017. just 4.87 in Louisiana to 54.60 in Maine.22 As noted in the map compiled by the National Council of State graduations, foreign-trained RNs still represent about Legislatures (NCSL) (Figure 10), all U.S. states face a 10% of annual new hires. primary care professional shortage, but the number of professionals needed to alleviate the shortage across Tools to Address Professional Shortages the states ranges from a few to more than 1,000. Working from HRSA’s data, NCSL determined that 59% Hospitals are implementing numerous strategies for of primary care shortage areas are in rural parts of the improving recruitment and retention. Hospital leaders U.S.23 As of November 2018, two-thirds of the nation’s shared examples of a number of financial tools used 6,941 primary care Health Professional Shortage Areas to attract and retain key staff, including retention and (HPSAs) were in rural or partially rural areas.24 three-year completion bonuses, as well as tuition reimbursement. Hospitals also employ a variety of Immigration Visas: To help meet their communities' incentive programs (both cash and benefits) to address needs, many hospitals rely on foreign-born employees shortages. Centering recruitment and retention to address their workforce shortages. As reported in a processes on the hospital’s mission and emphasizing Health Affairs study, 18.2% of U.S. health care workers the importance of service to others were two key were born outside of the U.S. (24% in certain lower- themes that emerged from interviews. Aligning skilled positions).25,26 According to a JAMA study, 29% mission, recruitment and retention can aid in identifying of U.S. physicians were born in other countries, and candidates motivated by the hospital’s mission. almost 7% are not U.S. citizens.27 Similarly, foreign-born nurses account for 15% of RNs in the U.S., according To reinforce the importance of mission and culture, to a report by the Institute for Immigration Research at hospitals are engaging in non-traditional activities, George Mason University.28 Despite growth in domestic including team-building events such as barbecues, ©2020 American Hospital Association | January 2020 Page 7 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning sporting events and volunteer opportunities. These Another solution to alleviate physician shortages is to activities keep staff connected to the hospital's mission increase the number of Medicare-funded residency and promote a team atmosphere. For technology slots. The AHA supports the Resident Physician and analyst roles, hospitals need to find new ways to Shortage Reduction Act (S. 348), which would add encourage and recruit candidates. As one interviewee 15,000 Medicare-funded residency positions over five said, “We need to make the pathway clear for years. The legislation would prioritize the distribution technology and analytic people, so they know these of the new residency positions to teaching hospitals as types of jobs exist in health care.” Rural hospitals in follows: hospitals in states with new medical schools or particular are expanding their strategies to address branch campuses; hospitals exceeding their graduate workforce shortages, taking a long-term approach by medical education residency slot cap; hospitals affiliated recruiting based on projected need rather than waiting with Veterans Affairs medical centers; hospitals that to fill a vacancy. emphasize training in community-based settings or hospital outpatient departments; hospitals that operate Rural hospitals are recruiting candidates with ties to the an approved “rural track” program in a non-rural area; community or training people from their communities and all other hospitals. Similar legislation in the House to meet workforce needs, rather than relying on simply (H.R. 1763) also would add 15,000 new residency trying to hire employees away from urban areas. Rural positions but would distribute them differently.33 hospitals also are relying heavily on APPs and are making use of telehealth and other new technologies The AHA is advocating to maintain and improve vital to mitigate certain labor shortages and meet their immigration programs. For example, AHA supports the patients’ needs. (See Telehealth on page 14 for more Conrad State 30 and Physician Access Reauthorization on this topic.) Act (H.R. 2895), which would improve the Conrad State 30 program and extend it until 2021. The Conrad 30 The National Health Service Corps (NHSC) assists waiver program allows J-1 medical doctors to apply for the rural workforce by awarding scholarships and a waiver of the two-year home residence requirement loan repayment to primary care providers. In fiscal upon completion of the J-1 exchange visitor program. year 2019, the NHSC received $319 million in award To obtain the waiver and eventually become a U.S. funding to recruit, retain and support clinicians in permanent resident, these doctors must agree to five high-need areas.29 Providers receiving a scholarship years of service in H-1B status in an underserved area. or loan repayment must commit to at least two years Most important of the reforms in H.R. 2895 is granting at an NHSC-approved site. NHSC-approved sites are immediate permanent resident status after this service. those that provide outpatient, ambulatory or primary The AHA is also seeking to protect visa numbers for health services in Health Professional Shortage Areas immigrant nurses and the preservation of family and (HPSAs). Several other loan forgiveness programs diversity immigration categories that supply most of the similarly facilitate growth of the workforce, including foreign-born health care workers in non-professional the Public Student Loan Forgiveness Program, the positions.34 Indian Health Service Loan Repayment Program and the National Institutes of Health Loan Repayment Financial Pressures Program.30,31,32 The average compensation of professionals across the Some hospitals are embracing artificial intelligence health care workforce varies greatly. Yet regardless of to help solve workforce shortages, particularly base compensation, the high rate of projected growth in administrative and office roles. (See Artificial in employment of several health care professions may Intelligence on page 14 for more on this topic.) spur more competition for qualified professionals and ©2020 American Hospital Association | January 2020 Page 8 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Figure 11: Average Compensation of Health Care Professionals Across the Health Care Workforce Estimated 2026 Employment BLS Occupation 2016 Employment Sum Median Salary Employment Growth by 2026 Medical Transcriptionists 57,400 1,900 59,300 3% $34,770 Physician Assistants 106,200 39,600 145,800 37% $108,610 Diagnostic Medical Sonographers 122,300 21,100 143,400 17% $67,080 and Cardiovascular Technologists Nurse Anesthetists, Nurse Midwives 203,800 64,200 268,000 31% $113,930 and Nurse Practitioners Medical Records and Health 206,300 27,800 234,100 13% $ 40,350 Information Technicians EMTs and Paramedics 248,000 37,400 285,400 15% $34,320 Medical and Clinical Laboratory 335,700 42,700 378,400 13% $52,330 Technologists and Technicians Medical Assistants 624,400 183,900 808,300 29% $33,610 Physicians and Surgeons 713,800 91,400 805,200 13% $208,000 Registered Nurses 2,955,200 438,100 3,393,300 15% $71,730 Source: BLS, Healthcare Professionals, www.bls.gov/ooh/healthcare/home.htm Note: The numbers cited above may not fully align with figures offered elsewhere in the paper due to slightly differing scopes of analysis and methodologies. increase salaries. Hospital interviewees expressed historically underpay hospitals for care provided to concern about their ability to retain staff in highly program beneficiaries). Combined underpayments competitive professions. (Figure 11) Student debt were $76.6 billion in 2018. This includes a shortfall poses another workforce challenge. Debt can push of $56.9 billion for Medicare and $19.7 billion for otherwise engaged staff to switch jobs based solely Medicaid. Hospitals also provided $41.3 billion in on compensation, which, in turn, can exacerbate uncompensated care.37,38 The combination of low shortages. Three-fourths of recent medical school reimbursement and high administrative burden makes graduates reported student debt, with an average of government programs challenging business partners $179,068 and 4% with more than $300,000 owed.35 for hospitals. Insufficient reimbursement limits overall The financial pressures of student debt push medical resources available to build the workforce, and low students toward higher-paying specialties, intensifying reimbursement also can deprive hospitals of the the primary care physician shortages discussed resources necessary to fully deploy the workforce tools elsewhere in this paper.36 Policymakers can assist discussed throughout this paper. hospitals and the health care workforce by expanding on the limited loan forgiveness opportunities that Health care is a heavily regulated field, and hospitals are currently exist. among the most heavily regulated health care entities. A 2017 AHA report estimated that hospitals were Reimbursement and Compliance Impact on subject to 341 unique compliance requirements (629 Workforce: More than half of all patients are covered if they provide post-acute services). All of the resulting by government programs, and nearly half of the requirements can lower morale and increase burnout by revenue paid to hospitals comes from government diverting provider attention from patients to paperwork, programs (primarily Medicare and Medicaid, which and by forcing the establishment of new teams focused ©2020 American Hospital Association | January 2020 Page 9 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning solely on appropriate data collection and reporting.39 2018.37 AHA also continues to advocate for increased This topic is touched on elsewhere in this paper. health care access (such as Medicaid expansion in states that have not expanded the program) in order to The rise of physician staffing services creates new improve health outcomes and lessen uncompensated demand for professionals, particularly specialist care. physicians – an industry trend born out of physician shortages but with significant financial repercussions. Burnout One staffing services expert noted that health- focused staffing companies grew 17% in 2018.40 One Across the U.S. economy, Americans are working interviewee, when focusing on behavioral health, more and exhibiting signs of burnout. Workplace expert noted the negative impact of venture capital-backed Christina Maslach defines its impact: “Burnout has companies luring away staff with high salaries. Staffing many consequences for the individual including physical services pose a long-term threat to hospitals if they can illness, increased feelings of hopelessness, irritability, successfully poach needed staff and then, in effect, impatience, and poor interpersonal relationships with rent that staff back to hospitals with a large mark-up. family/coworkers/others. In severe cases, burnout can cause diminished executive functioning, attention, Teaching hospitals depend on the federal government’s and memory. Burnout also has many organizational commitment to supporting the physician workforce consequences including absenteeism, increased through support of graduate medical education (GME). turnover, and decreased job performance.”43 As discussed above, one solution to alleviate physician shortages is to increase the number of Medicare- funded residency slots. With limits on how many GME slots Medicare will cover, hospitals find themselves The simple fact is … folks are burnt out, taking on a growing percentage of the burden to fund whether they’re nurses or doctors. their GME programs. Medicare spending overall and spending on graduate medical education have risen since 2001 but the cap on GME residents has not.41 The hospital workforce is not immune to this Tools to Address Financial Pressures nationwide problem. A recent National Academy of Medicine report identifies an imbalance in which To assist with student debt, hospitals offer tuition the demands of a clinician’s job are greater than the reimbursement programs for qualified employees resources available to complete the job effectively. and alert employees to loan forgiveness programs. The result is that between 35% and 54% of U.S. The AAMC also reports that nearly 40% of graduating nurses and physicians have symptoms of burnout, medical students in 2015 planned to participate in a which it characterizes as high emotional exhaustion, loan program that would forgive some level of their high depersonalization (i.e. cynicism), and a low sense debt.42 of personal accomplishment from work.44 Recognizing the link between workforce strategies Hospital workers may be especially susceptible. A and appropriate reimbursement, AHA and its member 2012 Truven study notes that hospital employees have hospitals advocate to improve hospital reimbursement 9% higher health care costs than the rest of the U.S. rates. In January 2020, the AHA published an workforce – a finding that raises questions about the Underpayment by Medicare and Medicaid Fact Sheet, impacts of job-related emotional and physical stress.45 which documented a $76.6 billion reimbursement A 2019 Medscape survey found that roughly 40% of shortfall from the major government programs in ©2020 American Hospital Association | January 2020 Page 10 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Tools to Address Burnout Work System Factors Contributing to Burnout Job Demands: There is no easy solution for burnout. However, several • Excessive workload, unmanageable work of the innovations noted elsewhere in this paper schedules and inadequate staffing have the potential to mitigate the impact of burnout • Administrative burden and address the underlying causes. To the degree • Workflow, interruptions and distractions that administrative burden is a contributing factor, it should be noted that many of these technologies and • Inadequate technology usability processes are still in their early stages and subject to • Time pressure and encroachment on change in the years to come. personal time • Moral distress The National Academy of Medicine advocates for • Patient factors taking a “systems approach” to mitigating burnout. Job Resources: Organizations should focus on identifying, evaluating • Meaning and purpose in work and implementing effective improvements at all levels • Organizational culture of the system by targeting known work system factors (job demands and job resources) that influence burnout • Alignment of values and expectations and well-being as well as learning and continuous • Job control, flexibility and autonomy improvement processes (informed by clinician and • Rewards patient feedback). The report suggests a six-goal • Professional relationships and social support approach: 1) create positive work environments; • Work-life integration 2) create positive learning environments; 3) reduce Source: National Academy of Medicine. “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being,” Oct. 2019. administrative burden; 4) enable technology solutions; 5) provide support to clinicians and learners; and 6) invest in research on clinician well-being. physicians claimed to have symptoms of burnout. A recent study on nurse burnout reports 15.6% of nurses Hospitals are seeing some success in reducing having such symptoms.46 Long hours and increasing burnout by implementing programs that can improve administrative tasks were cited as the primary causes.47 work-life balance and reinforce the commitment to the organization’s mission. A recent study of hospital Clinician frustration with a workload perceived as worker work-life balance (the authors call it “work- increasingly administrative and removed from patient life integration,” or WLI) concluded that: “Improving care is a major driver of burnout commonly identified this [hospital workplace] climate should be a strategic across our interviews. One interviewee from a small priority for leaders interested in building capacity rural hospital suggested that electronic health records and resilience in their workforce. Improving WLI is (EHRs) were a source of frustration. A recent study likely to improve health care worker’s quality of life, conducted by the Mayo Clinic gave the usability of organizational outcomes and, ultimately, quality of care current EHR systems a grade of F. It also concluded for patients.”49 that EHR usability was independently associated with the odds of burnout (based on the Maslach Burnout The AHA Physician Alliance recently released a guide Inventory).48 Another interviewee noted doctors and promoting well-being strategies that includes case nurses will suffer professional fatigue “if they don’t studies of tools implemented by several hospitals.50 feel they’re capable of doing what they went to nursing Novant Health, for example, implemented an executive school or medical school to do.” coaching program to support employees as well ©2020 American Hospital Association | January 2020 Page 11 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning as numerous organizational initiatives to address and security-call buttons; limited access to work burnout. The program has demonstrated a sustained areas to people with badges; limited guest hours; increase in employee engagement and significant installed metal detectors; increased police presence; success in improving patient experience.51 Similarly, implemented de-escalation training and emergency hospitals interviewed for this paper employ practices preparedness; and taken a variety of other steps.56 In such as allowing nurses to be more selective in their 2018, 57% of hospitals offered workplace violence assigned shifts and helping physicians train for (and be prevention programs.57 According to a 2017 AHA report, compensated for) other roles, such as administrative hospitals spent an estimated $1.1 billion in security and leadership. Finally, burnout symptoms may vary across training to prevent violence within their facilities, plus hospitals – one children’s hospital interviewee noted $429 million in medical care, staffing, indemnity and that his hospital built a highly committed and connected other costs resulting from violence against hospital workforce, which has helped combat burnout. workers.58 The AHA has implemented a Hospitals Against Violence initiative that has made available numerous resources to assist the field in this area. Workplace Violence In 2014, the Government Accountability Office (GAO) reported that the rate of serious workplace violence The Evolving Workforce incidents was more than five times greater in health care than in the general workforce. Further, BLS data Hospitals have sought to ensure that care is delivered in show that violence-related injuries are four times more the right setting at the right time. One observed trend likely to cause health care workers to take time off is that health care is increasingly delivered outside of from work than other kinds of injuries.51 Working with traditional settings. Care continues to shift away from 106 hospitals, the Occupational Health Safety Network inpatient settings, with a 2 million decrease in inpatient examined 2012 to 2013 data and found that nursing admissions between 2008 and 2017.60 assistants and nurses had the highest workplace Care delivery, particularly with regard to primary care, violence injury rates per 1,000 full-time equivalent is shifting from physician-centric to team-based models workers.53 A national survey of emergency medicine that combine physicians with RNs and APPs, including residents and physicians published in the Journal of nurse practitioners (NPs), certified registered nurse Emergency Medicine found that 78% of emergency anesthetists, clinical nurse specialists, certified nurse medicine physicians reported being targets of midwives and physician assistants (PAs). Richard workplace violence in the prior year.54 Tom Mihaljevic, Ricciardi of the Agency for Health Care Research and M.D., president and CEO of Cleveland Clinic, labeled Quality observes that: “NPs and PAs, who comprise workplace violence a “national epidemic” and notes approximately 30% of the primary care workforce, his health system confiscated a staggering 30,000 already play a central role in the delivery of a broad weapons from patients and visitors in 2018.55 range of primary care services, while leading practice Tools to Address Workplace Violence improvement efforts focused on quality and safety. The time for RNs to join them is here.”48 Hospitals are To reduce and prevent violence in the hospital setting, advancing the ability of APPs to work at the top of their hospitals and health systems have installed cameras licenses (while remaining consistent with state scope ©2020 American Hospital Association | January 2020 Page 12 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning of practice and other laws) and integrating nurses and their hospitals offer tuition reimbursement benefits at other professionals into team-based care models.49 local universities for staff pursuing degrees consistent with hospital goals. Most health care professions have annual continuing education requirements that must be satisfied to Rural health care’s savior is APPs with maintain active licensure. As a primary provider of telemedicine as a backup to assure that continuing education to many health care professions, hospitals can support and promote education and access and quality are always available training opportunities that align with the hospital’s out in these rural areas. workforce goals and licensure requirements for staff. Investments in the skills, training and education of staff is an effective approach to build and expand the A number of studies conclude that quality of care is hospital workforce. maintained when APPs play a more prominent role in the provision of care. A 2018 study in the American Training also plays a central role in retention, and Journal of Medicine, for example, concluded that for hospitals are offering new approaches to engage and nearly 20,000 diabetics over five years, “management train employees. These include leveraging technology by nurse practitioners and physician assistants was to increase the time clinicians can spend bedside, comparable to management by physicians.”63 While incentivizing serving on committees and presenting NPs and PAs are top of mind in most discussions at conferences, and other activities that focus on about APPs, other clinical roles also are important to individualized career progression and skills building. the evolving health care workforce. Certified registered One hospital interviewee addresses retention by nurse anesthetists (CRNAs), for example, provide strategically placing students and new graduates in services previously only offered by anesthesiologists. nursing, information technology and other positions to Particularly in rural hospitals, CRNAs are increasingly shadow and learn from more experienced staff. critical to a hospital's ability to perform surgery.64 The value of APPs to rural hospitals was further In May 2019, the North Carolina Medical underscored by the rural hospital CEO interviewed for Journal profiled a CNA apprentice program this paper: “Rural health care’s savior is APPs with co-implemented by CaroMont Regional Medical telemedicine as backup to assure that access and Center (CRMC) and Gaston Community College quality are always available out in these rural areas.” (GCC). In early 2019, CRMC “enrolled its first 20 CNAs into the CNA II apprenticeship Tools to Address the Evolving Workforce program.” The apprenticeship will permit CRMC’s participating CNAs to continue their Employee Education and Training: Education and education with a combination of on-the-job and training are necessary to develop staff into a dynamic GCC classroom training. At the conclusion of the and well-equipped workforce. Interviewees recognized apprenticeship program, participating CRMC CNAs the importance of training for multiple reasons: 1) will have expanded skills that can be leveraged retaining exceptional employees with professional by the hospital, and the CNAs will receive a growth opportunities; 2) training employees to meet corresponding salary increase. evolving needs; and 3) maintaining positive morale and Source: Goble, Patricia. “Preparing the Health Care Workforce Through loyalty. Many hospitals have developed detailed online Apprenticeship.” NC Medical Journal (2019): 160-161. staff training programs. Interviewees also shared that ©2020 American Hospital Association | January 2020 Page 13 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Telehealth: Telehealth is another important tool that about opportunities that AI and other IT-enabled enables hospitals to harness emerging technology in developments present in health care to augment care meeting the demands of the changing workforce. An without sacrificing human interaction and empathy at AHA report, Telehealth: A Virtual Path to Integrated the core of successful patient care. Care, notes that 97% of patients were satisfied with their first telehealth service. The report also notes that A Market Insights report from the AHA's Center 80% of virtual appointments “resolve the episode of for Health Innovation provides useful frameworks care” without visiting the emergency department (ED) and tools for hospital and health system leaders or another site of care. to successfully integrate AI technologies into their workforce and workflows. (Figure 12) The report highlights the potential of AI to produce better clinical, Telehealth operational and financial results, while also noting that A Path this transformation will require significant changes to Virtual Integrated in the composition, competencies and skill sets Care of the health care workforce. The Market Insights report also describes some of the new positions and responsibilities that will be needed to design, install, implement, run and monitor AI. MARKET INSIGHTS AI and the Hospitals are embracing telehealth in substantial ways Health Care Workforce in order to better serve hard-to-reach communities and ensure local access to care. The Medical University of South Carolina, for example, provides 77 telehealth services at more than 200 sites in 27 counties – 78% of which are in medically underserved areas. The How hospitals and health systems can use artificial intelligence to build the University of Mississippi Medical Center launched a health care workforce of the future MARKETINSIGHTS tele-emergency medicine program to connect small, rural hospitals to the Medical Center’s Level 1 trauma center.65 Yet even with increasing adoption, hospital Other New Technologies: According to McKinsey, use of telehealth is still in its early stages. One hospital a number of evolving technologies have the potential executive remarked: “I think we are just scratching the to transform hospital operations and workforce surface.” deployment, including: connected and cognitive devices, electroceuticals, targeted and personalized Artificial Intelligence (AI): In a recent Accenture medicine, robotics, 3D printing, big data and survey of health care leaders, respondents agreed analytics, blockchain and automation. Collectively, that machine learning can “help achieve previously these technologies can dramatically improve clinical hidden or unobtainable value,” and 86% agreed that productivity and reduce inappropriate use and enhance AI processes “are finding solutions to previously quality of care. The rate of technology adoption is unsolved business problems.”66 AI has been slower in health care than in other fields because of a deployed successfully to impact non-clinical business history of risk aversion and the highly regulated nature processes such as inventory management and of health care.67 While regulatory concerns cannot be revenue cycle. Hospital leaders spoke optimistically ignored, hospitals are positioning themselves for the ©2020 American Hospital Association | January 2020 Page 14 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Figure 12: New Roles AI Could Create in Health Care DATA SCIENTIST AI ENGINEER DATA GOVERNANCE DATA ENTRY EXPERT DATA ENGINEER CHIEF AI OFFICER This person knows This person builds the EXPERT This person curates, This person builds the This person leads how AI works and can AI models to perform This person makes sure cleans, scrubs and system that fuels the AI the effort to explore design AI models to the tasks required at the data are clean and structures data from a models with the data potential opportunities, perform tasks required a hospital or health accurate by setting the variety of internal and they need to perform develops a cogent AI at a hospital or health system. policies around how external sources into the tasks required at strategy and harnesses system. data are collected. They the system that feeds a hospital or health the necessary funding, are also responsible for AI models with the data system. professionals, making sure that when they need to perform technology and staff do their jobs, the tasks required at organizational they’re doing them a hospital or health resources to implement ethically, protecting the system. them. They must privacy and security understand the clinical of patients’ personal workflow – the front- health information, line workforce and the and following the data culture that drives care governance policies of delivery. the hospital or health system. Source: www.aha.org/center/emerging-issues/market-insights/ai/ai-and-health-care-workforce. big data future by hiring staff skilled in data analytics Remote Work Sites: Beyond telehealth, and health IT. regular work-at-home is growing rapidly – 140% since 2005. According to a survey from Global Applying clinical data analysis – such as those gleaned Workplace Analytics, 4.3 million Americans from patient acuity data and historical volume – to (3.2% of the workforce) now work from home staffing is producing positive results. According to a at least half the time. 40% more U.S. employers recent AHA Health Forum webinar, this data can be offered flexible workplace options than five years “aligned to help unit nursing managers determine how ago. Several interviewees noted having policies many nurses with which skill sets will be needed in that allow remote workers across a range of the coming days and weeks.” A program at Midland non-clinical departments, including information (Texas) Memorial Hospital “saw catheter-associated technology, billing/coding, call center, sales and bloodstream infections decrease by 64%” following finance. Particularly for professions such as IT, implementation of a staffing system that uses where remote workers are common, hospitals are “predictive analytics to identify future nurse scheduling assessing the market and implementing strategies needs.” There have also been decreases in “other to recruit and retain successful employees. hospital-acquired conditions as well, including falls and Source: Lister, Kate. “Telecommuting Trend Data,” globalworkplaceanalytics.com, Aug. 16, 2019. pressure ulcers.” And nursing turnover decreased 32% concurrent with these quality improvements.68 ©2020 American Hospital Association | January 2020 Page 15 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Hospitals are evolving to align themselves with the preferences and habits of the millennial It’s going to be a monumental change generation – as both patients and employees. once machine learning and deep One hospital leader interviewed for this paper suggested that 50% of hospital employees are cognition really take hold – and the whole millennials. Another interviewee pointed out that workforce is going to have to change. millennials change locales and jobs more readily than previous generations. An article in the Journal of Applied Business and Economics, citing BLS management positions from 15% in 2011 to 19% in data, notes that millennials “are retained on 2015. However, minorities represented a reported 32% average less than three years” by their employers. of patients in 2015.72 The preferences of millennials noted in this and other articles may also speak to broader societal Tools to Further Promote Diversity and Meet Evolving trends that could shape the preferences of post- Expectations millennial generations, and potentially influence older generations. Hospitals are building on existing diversity initiatives. Source: Campione, Wendy. “Corporate Offerings: Why Aren’t Millennials Staying?” Diversity recruitment and inclusion programs are a Journal of Applied Business and Economics (2015): 60-75. field norm and often include developing hiring goals, mentoring employees from minority backgrounds, A Diverse and Inclusive Workforce and employing recruiters from diverse communities to identify minority candidates for open positions. The U.S. is in the midst of major demographic changes. Interviewees for this TrendWatch discussed the value The Census Bureau projects that by 2045 the U.S. will of diversity training as a key component to quality of be “majority-minority”; that is, non-Hispanic whites will care and workplace retention. account for less than half the population.69 As the U.S. becomes more diverse, the health care workforce also As discussed in a bi-annual study conducted by AHA’s must reflect the diversity of the community. Institute for Diversity and Health Equity, successful diversity disparities elimination strategies within a Hospital leaders recognize that their communities and health care setting can address disparities by engaging organizations are diverse, and strategies to address communities, prioritizing diversity in leadership and diversity and inclusion should encompass veterans, governance, and delivering quality, culturally competent multi-generations and people of diverse religions, care.73 Interviewees for this report also noted the disabilities and sexual orientation.70 Research shows need to “grow their own” talent from within their workforce diversity leads to increased racial and ethnic communities to promote diversity, improve patient care minority patient choice and satisfaction.71 The changing and serve as a retention tool. face of America makes it a workforce imperative to ensure culturally competent, equitable access to care for all the people and communities we serve. Hospitals have made some progress in increasing workforce diversity, but there remains significant room for improvement. According to data from the AHA’s Institute for Diversity and Health Equity, hospitals increased diversity in their first- and mid-level ©2020 American Hospital Association | January 2020 Page 16 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning The AHA’s 2018 Equity of Care Toolkit outlines specific The health care sector faces challenges related to labor steps that hospitals and health systems can take to shortages and the impact of burnout on the workforce. improve diversity in governance and leadership:74 Regardless, hospitals are embracing opportunities to reduce administrative burden and augment care • Establish a mentoring program to help develop through technology. Looking to the future, the talent, regardless of gender, race or ethnicity. hospital sector must continue to evolve to reflect the changing care delivery models and the needs of our • Require search firms to present a mix of candidates communities. reflecting the community’s diversity. • Recruitment efforts should include strategies to Methods: This paper was informed by (1) structured reach out to racial and ethnic minorities in the interviews with five hospital executives from community. hospitals of different sizes, focus and geographic regions; and (2) a literature review supported by • Put a system in place to measure diversity progress a trained research librarian and supplemented by and report on it to leadership and the board. materials contributed by subject matter experts. The literature review was driven by a systematic • Identify community organizations, schools, places search of academic databases and legal databases, of worship, businesses and publications that and search engine reviews of trade and general serve racial and ethnic minorities for outreach and news publications, government publications and educational purposes. resources, nonprofit and research organization As part of its commitment to eliminating health and materials, and health care consulting reports. The health care disparities, the AHA also launched its search yielded approximately 90 sources that were #123forEquity pledge campaign. Hospitals and health sorted across 14 topic areas. Each was reviewed systems can take the pledge and commit to working prior to developing this TrendWatch report. The on efforts within their organization or in the community report does not cite all materials reviewed. related to health equity, diversity and inclusion, even if the efforts do not fit clearly under one of the pledge goals listed above. Policy and Strategy Questions 1.What regulatory or legislative changes are Conclusion necessary to support the hospital workforce and its continued development? A robust, skilled hospital workforce is essential to 2.How can policymakers support hospitals and delivering high-quality care. The economic impact of health systems in addressing the current hospitals extends beyond direct employment and has challenges in the health care workforce? a ripple effect on the well-being of local economies and communities. As large employers, hospitals face 3.How can payment models and care delivery the same national economic and societal trends as approaches complement workforce other sectors. The unique role of hospitals in ensuring development strategies? the health of their communities – both medically 4. ow should hospitals evolve their business H and economically – compounds the importance of models to support a nimble and agile workforce addressing hospital workforce challenges. of the future, and how must policy adjust to support those changes? ©2020 American Hospital Association | January 2020 Page 17 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning Other Resources • AI and the Health Care Workforce, Market Insights from the AHA Center for Health Innovation • Telehealth: A Path to Virtual Integrated Care, Markets Insights from the AHA Center for Health Innovation • The Hospitals Against Violence Initiative • Institute for Diversity and Health Equity • AHA Physician Alliance • Workforce Case Studies Sources 1. Levick, Richard. “Five Steps to Heal the Healthcare 15. 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American Hospital Association. “The Imperative for Strategic to VHA: Now is the Time to Grant CRNAs Full-Practice Workforce Planning and Development: Challenges and Authority,” newswise.com, Jun. 15, 2018. Opportunities,” aha.org, 2017. 64. Diesing, Genevieve. “How hospitals and health systems are 70. LaVeist TA and Nuru-Jeter A. Is Doctor-Patient Race using telehealth in rural areas,”aha.org, Nov. 27, 2018. Concordance Associated with Greater Satisfaction with Care? J Health Soc Behav. 2002 Sep;43(3):296-306. PubMed 65. Safavi, Kaveh et.al. “Healthcare: Walking the AI Talk,” abstract: www.ncbi.nlm.nih.gov/pubmed/12467254. accenture.com, 2018. 71. American Hospital Association. “Diversity and Disparities: 66. Dash, Penny et.al. “The hospital is dead, long live the A Benchmarking Study of U.S. Hospitals in 2015,” hospital!” mckinsey.com, May 2019. diversityconnection.org, 2016. 67. AHA Health Forum, “Developing a Health Care Workforce to 72.Ibid. Meet Current and Future Needs,” healthforum.com, 2019. 73. American Hospital Association. “2018 Equity of Care 68. Frey, William H., Brookings Institution Metropolitan Toolkit,” equityofcare.org, 2018. Policy Program, “The US will become ‘minority white’ in 2045, Census projects,” www.brookings.edu/blog/the- avenue/2018/03/14/theus-will-become-minority-white-in- 2045-censusprojects/, March 14, 2018. ©2020 American Hospital Association | January 2020 Page 20 | www.aha.org TRENDWATCH: Hospital and Health System Workforce Strategic Planning TrendWatch, produced by the American Hospital Association, highlights important trends in the hospital and health care field. Faegre Baker Daniels supplied research and analytic support for this issue. www.aha.org @AHAhospitals @AHAadvocacy facebook.com/AHAhospitals @AHAhospitals linkedin.com/company/american-hospital-association TrendWatch – January 2020 ©2020 American Hospital Association All Rights Reserved ©2020 American Hospital Association | January 2020 Page 21 | www.aha.org