How hospitals are tackling the challenges of in-house staffing programs

In fall 2021, when Ruth Brainerd, MSN, RN, learned about an in-house program of floating nurses at York, Pa.-based WellSpan Health, the idea of joining appealed to her.

That was because she was already a member of the float pool at WellSpan York Hospital, meaning she moved around to different units at the facility, she told Becker's.

"I liked floating, and this takes it to another level," Ms. Brainerd said. 

The fact that the manager of the WellSpan York Hospital float pool was going to be the manager of the WellSpan in-house program, called WellStaffed, also was enticing. 

"Even though I knew it was a new program — and she told me there would be bumps in the road — I already knew she had my back as a nurse in my previous department," Ms. Brainerd said. "I don't know if I would have been willing to join a new program with a manager I didn't know."

Fast forward to May and Ms. Brainerd is one of about 80 members of WellStaffed. Her career turn also is emblematic of hospitals looking internally to fill staffing gaps.

Seizing an opportunity

Throughout the pandemic, organizations have been tasked with addressing shortages of clinicians and other healthcare professionals, and many turned to third-party staffing agencies. 

But now some travel nurses at external agencies are seeing abrupt pay drops and canceled contracts. For example, Kaiser Health News found national demand for registered nurse travelers fell by one-third in the month leading up to April 10, according to data from staffing agency Aya Healthcare. 

Amid this issue — which Kaiser Health News partially tied to Congress failing to commit to additional COVID-19 funding — hospitals see an opportunity to establish their own in-house staffing programs to attract workers while decreasing contract labor expenses. Overall, labor expenses in hospitals rose 37 percent per patient between 2019 and March 2022, from $4,009 to $5,494 per adjusted discharge, a May 11 Kaufman Hall report found. This was largely attributable to contract labor expenses. 

Hospitals and health systems with internal travel programs said they view the initiatives as an effective strategy. Simultaneously, they acknowledge the challenges involved, such as monitoring demand and ensuring proper training. 

1 size does not fit all

At the outset, an internal travel staffing program must be part of a hospital's overall human resources strategy, according to Therese Fitzpatrick, PhD, RN, senior vice president of Kaufman Hall and a member of the firm's strategic and financial planning practice.

"Organizations that are finding this effective are doing other things like evaluating total compensation packages, doing a deep dive into what's happening in their particular market," she said.

For health systems with facilities across multiple states, their programs could involve travel agreements with individuals for six weeks or longer.

For other organizations, their programs might involve an enhanced float pool with some component of an internal travel company. 

Organizations "sort of fit in that space between a hospital-based float pool and this large travel company," Dr. Fitzpatrick said. "We see some interesting things happening with salaries as well as tipping that salary equation, so staff is recognized for not only working across multiple hospitals but potentially across multiple clinical areas within those hospitals as well." 

'They're our boots on the ground'

WellSpan launched its program last year because of challenges meeting staffing needs across the eight-hospital health system as patient volume increased due to the pandemic, said Tina Martin, DNP, RN, senior director for system nursing at WellSpan Health. 

"We were getting nurses from external agencies, but the cost of doing their hourly rate was increasing, so we were trying to think of innovative ways to meet the staffing need without incurring that big expense," she said. 

The goal with WellStaffed is to meet long-term needs. 

If a hospital needs a nurse in the short term, it uses its own internal float pool, but if the hospital needs nurses because someone is on an extended leave of absence or there is an an open position not ready to be filled, the hospital could get a WellStaffed nurse to fill the longer-term need, Dr. Martin said. The WellStaffed nurse could be assigned to a facility for as few as two weeks.  

"The strategy for WellStaffed is we will hire the amount of WellStaffed positions that equal what our average leave of absence is," Dr. Martin said. "The purpose is to cover nurses who are out on leave of absence, but it also provides us with some agility, so if we have a hospital that needs to increase their patient census because of a pandemic or other reason, it does give us a pool of nurses we can use to temporarily supplement their staffing."

She said another benefit is WellStaffed participants are WellSpan employees, so they have a dedication to the organization and their work that someone from outside the organization might not have. 

"We like that it's our employees. They understand our core values. They know what our goals are, what our initiatives are. They know our policies and procedures," she said.

Dr. Martin said WellSpan also found that because WellStaffed nurses go from hospital to hospital, they can identify areas that need improvement. 

"When you have eight hospitals across five counties, you are likely to have some discrepancy here and there, so our WellStaffed nurses have been doing a great job of giving us some feedback on what the opportunities for improvement are and how we can improve consistency across all our hospitals," she said. "They're our boots on the ground." 

Early adopter in Detroit

Detroit-based Henry Ford Health's BestChoice Internal Staffing Resource Pool started years before WellSpan's program, but it was launched for similar reasons. 

When BestChoice began about a decade ago, the goal was to provide flexible options for workers, according to Eric Wallis, DNP, RN, senior vice president and system chief nursing officer of Henry Ford Health.

"Even going back a decade, one of the biggest challenges in healthcare is making sure you've got the right resources in the right place at the right time," Dr. Wallis said. "This was a program we saw that had been in place at a few health systems around the country. It was at that time a unique and innovative way to look at your workforce and help us better manage [labor] cost[s] in some respects." 

Over the years, the size and scope of the BestChoice program has evolved.

Dr. Wallis said BestChoice began with about 50 people, but throughout the years Henry Ford Health has added more nurses and team members to the program as well as more roles. 

"There was a point in time where we had physical therapy and occupational therapy staff members in the BestChoice pool," he said. "Now they transitioned back out of the pool.

"In 2019, as we looked at this, we added medical assistants. We've looked at areas outside our acute care hospitals. We've brought nurses in for home care, hospice. We've now brought in LPNs, some of our environmental services folks, emergency room techs. We've continually evolved the pool of people and what makes sense for us given what our day-to-day needs are. We also have [emergency room] techs now. We have respiratory techs now in the program."

Currently, there are about 470 nurses, more than 90 medical assistants and about 25 other professionals such as techs and nursing assistants in the BestChoice pool. They are deployed daily across five hospitals, urgent care sites, 126 ambulatory sites, home care, hospice and other locations. 

"We're constantly looking at what's the right mix of people, and what are the right places we can deploy and use those skill sets to better manage the healthcare workforce," Dr. Wallis said. 

Most people in the BestChoice pool are contingent workers, although Henry Ford Health can enter into an agreement with a worker if a site has a specific need and wants to enter into such an agreement with an individual to use full time in a unit, he said.

Navigating rough waters

In-house travel programs are not without their challenges. 

For example, Dr. Fitzpatrick said sometimes there is a fear that there's going to be a migration of staff from their current roles into in-house travel staffing positions. However, "those are very controllable [phenomena]," she said. 

"Positions would be posted for roles within an internal travel company or original float pool, and there would need to be a negotiation with the manager and the employee in terms of when they might migrate to that new position. We're finding clinical leaders are effectively managing that," Dr. Fitzpatrick said.  

Dr. Martin, with WellSpan, said another challenge is ensuring in-house travel workers have the correct training when they go to different hospitals because operations are not identical at each facility. To address this, the WellStaffed manager visits hospitals to check on nurses in the program. They also have support from their unit manager. 

"Hospitals considering a program must ensure a person is embedded into the unit and getting information [to workers] related to any changes in nursing practice or initiative they need to focus on or new piece of equipment," Dr. Martin said. "If that person isn't on your unit email list, they could be missing some critical information."

Dr. Wallis agreed with this approach. 

He said Henry Ford Health works hard on communication with BestChoice participants via its own scheduling and processing procedures. Dr. Wallis said the health system is also standing up a central staffing office to improve communication between BestChoice leadership and leadership of individual care sites. 

Pay is another issue for consideration when starting an in-house travel program, Dr. Wallis said.

"The reality is, because these workers are paid at a premium compared to our regular full-time, part-time staff in the acute setting, it was very attractive for those folks who may not need benefits or may be willing to have that kind of flexibility," he said. "They do get a premium pay to be in this pool. We're very thoughtful about how much of a differential there is between the folks in the BestChoice pool [compared to] regular jobs at our sites because it is a balance to make sure we're not pouring too many of our highly skilled folks out of their home units."

He said Henry Ford Health also recently looked at how the health system can use BestChoice as an option for people considering traveling. That prompted the health system this year to add roles with full benefits within the BestChoice pool. 

Dr. Wallis said the health system posted about 50 of those roles and quickly saw interest, with some converting from a contingency job in the in-house program to a full-time or role with benefits in the program. 

Additionally, he said the health system must ensure members of BestChoice are experienced. The program requires participants to have a couple years of experience before they step into an in-house traveling role.

"Really across the country one of the most interesting pieces of this travel nursing effect was they were often taking people with little or no nursing experience coming right out of school," he said. "We saw that as being a challenge to us. But our BestChoice folks this past year worked more than 400,000 hours across system. It's a huge component of our workforce and helping us fill the gaps where we need them."  

'Understand how demand behaves'

Dr. Fitzpatrick encouraged hospitals considering in-house programs and the cost involved to understand demand. 

For example, a float pool in that midsize market must have an effective geographic or regional float pool, she said.

"You have to be able to right size it. To do that, you need to understand how demand behaves at each of those hospitals. If you don't, you're going to undersize it, and that won't be effective," she said.  

In contrast, "if you oversize it, that becomes really expensive to the organization," she said. "So, sort of understanding what demand by clinical specialty within the hospital is important."

Dr. Fitzpatrick also encouraged larger health systems to understand seasonality based on their market.

All these and other considerations are top of mind for CommonSpirit Health, a 142-hospital system based in Chicago. CommonSpirit was formed through the 2019 merger of San Francisco-based Dignity Health and Englewood, Colo.-based Catholic Health Initiatives. Now the health system is planning an in-house travel program.

Kathy Sanford, DBA, RN, chief nursing officer of CommonSpirit told Becker's the organization's goal is to hire 500 internal travel registered nurses as well as certified nursing assistants, respiratory therapists, surgical techs and other healthcare professionals who may want to travel.

As part of that goal, the health system plans to hire up to 250 registered nurses by June 30, 2023, and eventually hire up to 500.

"Right now, we have all the work that has to be done," Dr. Sanford said. "You have to figure out the logistics of who's going to manage [aspects of the program], what software you're going to use for assignments, and you have to get job descriptions done."

Internal travel positions will be posted five at a time.

Meanwhile, CommonSpirit has also standardized onboarding to prepare for its internal travel program, Dr. Sanford said. 

The health system anticipates the program will go live June 22 in Arkansas and expand from there. 

"We won't launch in all states at once," she said. "We will first launch in the Southeast division, which is Arkansas, Kentucky and Tennessee. We believe we will have first travel nurses ready to get started in Arkansas June 22."

In addition to staffing, Dr. Sanford said one challenge in rolling out the program is finding the right leader. 

"[This] is important because we need people who have experience in that. We believe great leaders can lead anything, but there is also a need for expertise and subject matter experts," she said. "A challenge is getting the right people to lead it who know how to lead this kind of business."

Gail Daly, CommonSpirit's system senior vice president for clinical operations, integration and optimization, will run the health system's program.

And in the end, Ms. Sanford said CommonSpirit Health's goal is to hire employees who want to spend their careers with the health system. 

Ms. Brainerd, with WellSpan, plans to stay in her own health system's internal travel program long term.

"I love it. I've been having a lot of fun with it because I like seeing and doing new things," she said. "This gave me the opportunity to see and do new things and still be in WellSpan."

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