Resilience

Leadership

July 2014

Population Health Management

Patient-CenteredCare

CONVERSATION:Accelerating workforce transformation in healthcareChanging the

Culture Change

Supported by The Healthcare Workforce Transformation Fund Training GrantCoordinated by Karen Moore, R.N., FACHE, Consultant, KMoore & Associates

Team Intelligence

     MHA, through a grant from the Workforce Transformation Fund, presents this report, Changing the Conversation: Accelerating Workforce Transformation in Healthcare. We thank our more than 430 members who participated in the survey, which included interviews with leaders from hospitals around the commonwealth.  The results of this survey present a call to action for executive leadership. The need to re‐design care around patients, engage in culture change, and leverage team intelligence have emerged as leading workforce goals throughout healthcare organizations. While re‐tooling the current workforce, leaders need to recognize the magnitude of the changes and the effect they will have on workers. The survey shows that resilience is a key factor in enabling the transformation to be successful.  We’re learning that leaders can help transform their workforce by being a visible force for change and by supporting the retraining efforts within their organizations. This is an exciting and challenging time, and if done right, caregiving will gain effectiveness and efficiency.    MHA plans to use this data to create a roadmap for our educational efforts over the next 3‐5 years. We will disseminate this report liberally in hopes that it will help provider organizations focus on training strategies to help the healthcare workforce evolve.  We welcome your perusal of our survey report and look forward to hearing your thoughts on it.  Sincerely,  

  Lynn Nicholas, FACHE President & CEO Massachusetts Hospital Association 

TABLEOFCONTENTS

ExecutiveSummary……………………………………………………………………………………..p.1

I. Introduction……………………………………………………………………………………..p.2

II. Background………………………………………………………………………………………p.3

III. MethodsofInquiry……………………………………………………………………………p.4

IV. ReportofFindingsfromQualitativeInterviews………………………………….p.4

V. Survey……………………………………………………………………………………………...p.13

VI. SummaryofFindings………………………………………………………………………..p.19

VII. Weakness/BiasesandLimitations…………………………………………………….p.20

VIII. Conclusions……………………………………………………………………………………..p.20

Acknowledgements…………………………………………………………………………………….p.23

ReferenceInformationalSourcesandRecommendedArticles………………………p.24

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ChangingtheConversation:AcceleratingWorkforceTransformationinHealthcare

EXECUTIVESUMMARY

Hospitalsandhealthsystemsneedtoaccelerateworkforcetransformationsothattheycanbesuccessfulinmakingthewide‐scalechangesneededtoredesignhealthcare.Togaingreaterunderstandingoftherealitiesofworkforceneedsandchallengesoverthenext3‐5years,theMassachusettsHospitalAssociation(MHA),fundedbyaWorkforceTransformationPlanningGrant,interviewedadiversesampleofleadersatMassachusettshealthcareorganizationsandconductedabroadsurveyofitsmembership.Acomplexpictureofemergingknowledge,science,androlesemerged,convergingonthechanginghealthcaredeliverysystem.Mostofthe459,000healthcareworkersinMassachusetts1havebeenpreparedforamodelofcarethathasbeenhospital‐centric.Yet,shiftingsitesofcare,accountabilityforcaremanagement,amorepatient‐centeredfocus,andnewskillsinteamcarearedrivingtheneedforchange.

Thechallengeofretoolingtheexistingworkforceisunprecedented.Duressamonghospitalworkersisevident.Despiteincreasedemploymentrates,healthcareworkforceproductivitynationally2continuestobethelowestthroughoutallsectors.Respondentswanthospitaleducationeffortstobemoreapplicabletochallengestheycurrentlyface,focusingmoreondealingwithchangemanagementandteamtraining.Specifically,theypointtoaneedforcreatingvaluefortheworkforcewherelearningpertainsdirectlytosupportingteam‐basedapproachestocare.Andthereisaneedforabroaderunderstandingofnewrolesandhowtheyoverlapwithexistingroles,aswellassupportofindividualcapacitytocopewitharapidlychangingenvironment.

Alleffortsatworkforcetransformationmustcomefromtheperspectiveofthepatient,respondentssay.Involvingpatientsandchroniclingpatientjourneysthroughtheirhealthcareexperiencewillbekey.Althoughtherehavebeeneffortsatimprovingthepatientexperiencethroughcustomerservicetrainingandprocessimprovementefforts,somefeeltheseeffortshavenothadtheexpectedimpact.Acceleratingtransformationwillcomenotjustfromwhatworkersdo,buttheconsciousnesswithwhichtheydoit.Itisthereforeessentialtoinvolvefrontlineworkersintheredesignofhealthcaredelivery.

Leadersandworkerswillneedtoshiftfromrigidroleandtaskorientationtowell‐definedcareerframeworksthatpromoteflexibilitytochangerolesandsettings,developnewcapabilities,andalterprofessionalfocusinresponsetothechangingenvironmentandtheneedsofpatients.Attentiontoroleintroduction,teamtrainingandinter‐professionallearning,aswellastheindividualworker’s

1 Massachusetts Healthcare Chartbook, Executive Office of Labor and Workforce Development, Commonwealth Corporation, Fall 2007, page 7. Accessed 7/25/2014

2 Kocher and Sahni, “Rethinking Health Care Labor,” New England Journal of Medicine, October 13, 2011

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needforself‐care,reflection,andresilience,willallowcreativity,innovativelearningandcompassionateenvironmentsofcare.Finally,commitmentisneededtodedicateresourcestosupporteducationandtraining.Giventhewidescaleofworkforceredevelopmentneeded,thiscanbefacilitatedthroughcentralizedlearningcollaboratives,includingbothpublicandprivatefunding.

I. INTRODUCTION

ThepurposeofthisreportistoobtainacurrentunderstandingofhowhospitalandhealthsystemsinMassachusettsaretransformingtheirworkforcestomeettheneedsoftherapidlychanginghealthcarecommunity.

Massachusettshasledthenationintheredesignofhealthcaredeliveryoverthepast10years.Yethospitalsandhealthsystemsthecommonwealthareunderincreasingstrain.IntheU.S.,healthcareexpenditureshavegrownto17%ofGrossDomesticProduct(GDP),withprojectionstogrowto20%by2020.3However,inMassachusettstheunadjustedpercapitacostofcareissignificantlyhigherthantheU.S.average.Evenafteradjustmentforriskfactors,spendingis20%higher.

Whenlookingsolelyathospitalcare,MassachusettsexceededtheU.S.averageby41.6%,4andinlong‐termcareandhomehealthby72%.5Massachusettscostscontinuingonthistrajectorywilldoubleby2020.Furthermore,between2001and2011,theMassachusettsstatebudgethasincreasedby59%($5.1Billion)whileothersocialsupportneedssuchaspublichealth,mentalhealtheducation,andothershavebeencutby$20%($4Billion).6

Significantshiftsaretakingplacecatalyzedbyhealthcarepaymentreformtocreatenewandlargerhealthsystems,forgenewpartnershipsbetweenprovidersthroughoutthecontinuumofcare,andpilotinnovativewaystodeliverhealthcaretomeetthe“tripleaim”:improvingthepatientexperienceofcare(includingqualityandpatientsatisfaction),improvingthehealthofthepopulation,andreducingpercapitacostsofcare.

HealthcareemploymenthasoutpacedoverallemploymentintheU.S.,andyetthehealthcareworkforceislessproductivenowthanitwas20yearsago.(Productivityisdefinedastheoutputofvolumeofactivityperunitofcost.)InanarticlebyRobertKocher,M.D.andNikhilR.Sahni,publishedintheNewEnglandJournalofMedicinetitled“RethinkingHealthCareLabor,”theauthorsreportthatanyefforttoslowtherateofhealthcarespendingwillrequireachangeinlaborstructurebyreducing 3 Center for Medicare & Medicaid Services, National Health Expenditure Projections 2010-2011, Forecast Summary, Table 1, page 4.

4 The Henry J. Kaiser Family Foundation, Health Care Expenditures per Capita by Service by State of Residence, 2009, http://kff.org/other/state-indicator/health-spending-per-capita-by-service/ for notes and sources

5 Health Policy Commission, 2013 Cost Trends Report, July 2014 Supplement, p.12

6 Building a System of Care for Greater Value, presentation by Howard Grant, J.D., M.D., for the American College of Healthcare Executives, July 1, 2014

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workers,loweringwages,orincreasingproductivity.Approachesthatencourageredesignofcaredeliverybyusingadifferentquantityandmixofworkersengaginginamuchhighervaluesetofactivitieswilldeliverthemostvalue.Theygoontocitetheneedtoleveragetechnologyandstandardizationofworktohelpeliminatewaste.Theauthorspointoutthateveryothermajorsectoroftheeconomyhasmanagedtosimultaneouslyimprovequalityandconsumersatisfactionwhilereducingcost.Thesameshouldbeachievableinthehealthcaresector.

InarecentHarvardBusinessReviewarticlebyMichaelPorterandThomasLeeM.D.titled,TheStrategyThatWillFixHealthCare:ProvidersMustLeadtheWayinMakingValuetheOverarchingGoal,theauthorsstate:“Wemustmoveawayfromasupply‐drivenhealthcaresystemorganizedaroundwhatphysiciansdo,andtowardapatient‐centeredsystemorganizedaroundwhatpatientsneed.”Dr.Leeremarkedinarecentpresentation,“Thechallengewithcaredeliveryforprovidersisthattherearetoomanypeopleinvolved,toomuchtodo,noonewithalltheinformation,andnoonewithfullaccountability.Theresultischaosanditleadstogapsinquality,safetyandefficiency.Thehealthcaresystemisunderduress.Weneedstrategiesthattranscendthepaymentmodel.Improvementofvalueisthemostrobuststrategyforallofthemajorproviderleversforsuccess.”

Theworkforceitselfisgettingincreasedattention.Howcantheworkforcetransformtoachievethetripleaim?Providersandworkersarebeingrequiredtolearnnewskills,workacrossnewboundaries,andcollaborateinunprecedentedwayswithcolleaguesaswellaswithpatientsandfamilies.However,workforcedeploymentremainsrigidandproductivitylags.

II. BACKGROUND

ThisreportwasmadepossiblebytheWorkforceTransformationFundPlanningGrantincludedinChapter224,whichwaspassedin2013withthegoalofbringingMassachusettshealthcarespendinggrowthinlinewithgrowthintheoveralleconomy.Thelawincludesmanyreferencestoimprovingthequalityofcareandbuildsontwopreviouslawsenactedin2008and2010thatexpandeddatatransparencyandreportingoncosttrendsanddriversaimedtocontrolpremiumgrowth.ThecomprehensiveChapter224introducedmandatesforprovidersandhospitalstoreviewcurrentpracticesandtoseekwaystofurtherimproveandredesigncare.

Thisgrant‐fundedproject,executedbyMHA,wasdesignedtogainunderstandingofthehospitalworkforcetrainingneedsnowandoverthenext3‐5yearsfromtheperspectivesofseniorexecutives,middlemanagers,andfrontlinestafffromMHAmemberhospitals.

OverthepastyearMHAhaslaunchedTheInstituteforCareCoordinationtoprovideeducationonskillsandexpertiseneededtoexcelatpopulationhealth/carecoordination.Thecarecoordinationroleisclearlyastartingpoint.ParticipantsintheInstitute’seducationalforumshavereportedhighvariabilityinunderstandingreformandothernewrolesbeingintroducedtopatientcaredeliveryenvironments.

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Themovetonewmodelsofcaredeliveryiscreatingchallengesforworkersindifferentways.Somechallengesincludeunderstandingtheresourcesavailableinthecommunityforadequatecareplanning.Oneparticipantwhotookpartinthesurveystated:“Carecoordinationisworsethaneverwithfragmentedandcumbersomeelectronichealthrecords,changingfamilydynamicsbroughtonbyworkingfamiliesandsocioeconomics,andhealthcareproviderswhodon’treallyknowthepatient.”ManyoftheattendeesattheInstitute’sprogramsreportedafeelingofdisempowermentandconfusionaboutwhosejobitisto“fixthings.”Asignificantstressorreportedwasfeelingcaughtbetweensupportingpatientsandtheexpectationsforreducingcostswithoutfeelingtheyhadavoiceoraplaceformeaningfulinvolvementinchange.

Thisreportseekstounveilinformationanddatagleanedfromthisprojectthatwillhelphospitalsandhealthsystemswiththeirworkforcestrategies.ItisalsointendedtoassisttheMassachusettsHospitalAssociationoverthenext3‐5yearstoprovideneededsupport,education,andtrainingtoaccelerateworkforcechangesinthecaredeliveryenvironment.

III. METHODSOFINQUIRY

Themethodofinquirywastwofold:

1. Qualitative:Structuredinterviewswithhospitalleaderstogetinsights,perceptionsandthinkingfromthoseresponsiblefortheplanninganddeliveryofcare,andalsotoinformthedesignofthequantitativesurvey.

2. Quantitative:Thedisseminationofasurveytoobtaindataaroundknowledgeandskilldevelopmentneededinthehospitalworkplace.

TheprojectenlistedthesupportoftheGallupCompanyforsurveydesignandtoconductsomeoftheinterviews.

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REPORTOFFINDINGSFROMQUALITATIVEINTERVIEWS

Atotalof16interviewswereconductedusingastructuredinterviewapproach.Participantswereallinvolvedwiththeplanninganddeliveryofpatientcareservicesandwereselectedtorepresentdiversemissionsandgeographiclocations.

Followingarethesetofquestionsposedtointervieweeswithsummarizeddescriptionsofthemeswhichemergedamongtheresponses.

1. Whattrendsorchangesinhealthcaredeliveryareofthegreatestinteresttoyourightnow?

Theresponsestothisquestionfellinto6themes:

DecliningreimbursementsresultingintremendouscostpressuresMHAmembersarefamiliarwiththeoverarchingissuesunderpinningtheneedforexpensereduction.However,seniorexecutivesandmanagersshouldnotoverestimatetheirworkforce’sunderstandingoftheseissues.ThereisagreatdealofvariabilityinbasicunderstandingoftheAffordableCareAct(ACA)andtheshifttonewpaymentmodelsorhowhospitalbudgetsevenwork.Oneoftheintervieweeswholedtheeducationalprogrammingofahealthcareorganizationstatedhehadfoundthiswassotruethatthehospitaldevelopedtutorialstobedoneonlinethatwereprerequisitesforsomeofthemoreadvancededucationalofferings.

Notallintervieweesledwiththeconcernofreducingexpenses.Therewasconsiderableawarenessofaneedtoprovidehealthcaretoapopulationofpeoplewhoseinsurancegivesthemgreateraccesstocarealongwiththeimplicationsforpartnershipsandcollaborationsthatneedtobecreatedinordertoachievethem.

Newmethodsofcaredelivery,providerrolesandpaymentmodelswiththedevelopmentofACOsandmedicalhomesMostintervieweesidentifiedchallengeswithworkingacrossmedicalsubspecialties,coordinatingpost‐acutecare,andcommunity/home‐basedservices.Newrolesarebeingcreatedorintroducedinnewsettings.Oneseniornursingleaderstated:“AneedforNursePractitionersisexploding.”

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Inaddition,thereisashiftoftaskstoless‐skilledworkerswhiletheprofessionalcaredeliveryteamexpandsinitsexpertisetoincludepharmacists,nutritionist,andbehavioralhealthspecialists.Eventheseprofessionalsinnewsettingsrequiremoreflexibility,newskills,andcompetencies.

SocietalIssues:Demographicsofanagingworkforce,mixedgenerations,lackofdiversityintheworkforce,andsocioeconomicdisparityIntervieweesdiscussedthefactthattheworkforceoftendoesnotculturallyorethnicallyreflectthepatientpopulationbeingserved.Therearealsomixedgenerationsintheworkforce.With“organizationalculture”definedas“whathappenswhennooneislooking,”differentculturalperspectivesmayhinderstandardizingapproachestocare.

Thewillingnessofotherstospeakupwhensomeoneisn’tfollowingthroughisseenasimportanttobasicsafety.Thisischallenginginhospitalswithstronghierarchicalstructuresandtitlessuchas“Chief”and“Director”orwithleaderswhomaynotreflecttheculturaldiversityoftherestoftheworkforce.

Someorganizationshavereportedaddressingeconomicdisparitybyalteringbenefitsstructuresforlowerpaidworkers.

ShiftsawayfrominpatientutilizationAnactualoranticipatedtrendoflowerinpatientcensuswascited.Thesystemofcaredelivery,suchasitis,issetupsoitoftenworkseasiestonceapatientisadmittedtoahospital.Forexample,apatientreceivingcomplexcareintheemergencyroom,whoalsohasaknowndiagnosisandtreatmentplan,oftenendsupinaninpatientbed.CaseMangersinemergencyroomshavebecomecommonandhaveshiftedthefocusofemergencyroomcareplanning.Intervieweesdescribedcareplanningasgettingmorecomplex,requiringknowledgeofcommunityservicesandotheraspectsofthecontinuumofcare.

Theothersignificantimpactoflowerinpatientcensusisthattheinpatientsettinghastraditionallybeenwherecliniciansreceivedtheirtrainingandareexpectedtoworkwhenenteringtheworkforce.Manycliniciansfindtheycannotgetpositionsinhospitalsandareconcernedabouttheircareerchoice.Thereisgrowingdemandforcliniciansinmedicalhomes,outpatientsettingsandinthecommunity.Eventhesepositionsweredescribedastakinganexpertiseandfoundationoflearningfromhospitalexperience.

Abouthalftheorganizationsrepresentedbytheintervieweeshavenotyetexperienceddecreasinginpatientutilization,butareanticipatingafuturetrend.Theyhavebeenactivelylookingatpopulationswhoareusinginpatientservicesandcouldhavebeencaredforinalower‐costsetting.Someoftheseeffortsareresultinginshiftsofinpatientvolumefromtertiarycaretocommunityhospitals.

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Informationtechnologyandbio‐technologyIntervieweesdescribedtheincreasingcapitalneededtodevelopandstaycurrentwithdemandsforpatientcare,data,andreportingneeds.Aphysicianreportedhavingtospendthreehoursdocumentingcareafterseeingapatientforanhour.ImplementationofanElectronicHealthRecord(EHR)wasoccurringinallofthehospitalsrepresented.Insomecases,thehospitalwasgoingfromapapersystemtoanEHRforthefirsttimeandothershadanEHRandweregoingtonewplatformsandvendors.AdoptingEHRsrequireslengthyplanningandimplementationperiods.Increasinginformaticsstaff,particularlycliniciansintheseroles,wasalsoatrend.

ThenewconsumerismofhealthcareandincreasedaccesstocareMorepatientshaveaccesstocareandarecoveredbyinsuranceplanswithhigherco‐paysanddeductibles(thatmayvarydependingonwheretheygoforcare).Thismayresultinpatientsseekingcareinlower‐costsettingsorforgoingcare.Thepatientwantstoknowwhatthecostimplicationsforcarewillbewhenaplanofcareorcourseoftreatmentisbeingdiscussed,representingincreasedchallengesforproviders.Atthesametimea“retail”environmentforhealthcareisemerging,givingcontinuumsmorechoicesbutdisruptingcontinuityofcareopportunities.

2.Hashealthcarereformrequiredyoutodevelopnewrolesorskillsinyourorganization/position?Howhaveyoudonethat?Hasitbeensuccessful?

Allintervieweesreportedthedevelopmentofnewrolesorskillsintheirorganizationsasaresultofchangesincaredelivery.However,mostdiscussedtheneedforamoreflexibleworkforcewith1)existingworkerstakingonnewrolesinnewmodelsofcare;2)shiftingemploymentsettings;and3)movingbetweenneededspecialtiesandchangingservicesoffered.

TakingonNewRoles:AfocusontheroleofnursingTheneedfornursepractitionersandthelackofthemwasasignificanttheme.Insomecasesteachinghospitalspartneredwithschoolsofnursingtoplaceadvancedpracticestudentsinclinicalsettings.Somecurriculumhasbeendevelopedtoaddresstheacculturationofnursepractitionersintoprimarycarepracticesettings.Despitethedecades‐longexistenceoftheroleofAdvancedPracticeRNs(APRNs)itwasfeltthatthereisstillalackofunderstandingoftheirroleandhowitisdifferentiatedfromthephysicianassistant.

Oneseniornursingleaderstatedthat,“theACAhasopenedupaccesstocare.However,oursystemsofcaredeliveryarenotready,particularlyforprimarycare.Massachusettshasnotbeenaleaderwithregardstotheroleofthenursepractitionerasitrelatestoregulationandreimbursement.Withanincreasingvolumeofpeopleseekingcare,therearedelaysinaccesstocare.Peoplearebeingseenwhentheirillnesstrajectoryhasmovedtoamoreacutelevel,resultinginsickerpatientsbeingseeninthehospital.Thisistrueforthosewithmentalillnessaswell.”

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Manyoftheintervieweestalkedabouttheroleofnursingingeneralandreferencedthe2010InstituteofMedicinereport,TheFutureofNursing:LeadingChange,AdvancingHealth.Recognitionthatcaredeliverytakesateamandnursingcaredeliveryrequiressupportenablesnursestoworkat“thetopoftheireducation”andawayfromautilitarianfunction,andallowsthemtomovetowardsaccountabilityforcaremanagementandcoordination.

Thereisanincreasingneedcitedfornurseswithspecialtycertificationintheinpatientsetting,suchascriticalcare,emergencycare,andsurgicalnurses(includingRNfirstassistantstosurgeons).Traditionally,newgraduatenursesdidnotenterintotheserolesbutnow,almostallofthoseintervieweddescribedprogramstobringnewgraduatesdirectlyintospecialtyprogramswithextensiveorientationandmentoring.Insomecasesthishascreatedaddedstressforstaffsthatmaintainassignmentlevelswhilesupportingnewstaffacquiringcompetency.Someorganizationsweredevelopingnurseresidencyprogramsfornewgraduates.

ShiftingemploymentsettingsAspatientsmoveawayfrominpatientcarethereismoredemandforexperiencedRNsintheoutpatientsetting.CaseManagers(mostfrequentlynurses)wererecognizedashavingthesignificantrolechangeasitrelatedtodemandstoachievecontinuityofcarewhilemanaginglengthofstayandutilizationofservices.Theserolesareappearinginemergencyrooms,medicalhomes,andfollowingpatientsacrosscaresettings.Thetraininginvolvesbecomingmorefamiliarwiththeservicesavailableinacommunityinordertoputtogetheracomprehensiveplanofcare.

NewandexpandedrolesTherearenewtypesofhealthprofessionalsperformingnewfunctions.Forexample,healthcoachesandpatientnavigatorsarebeingimplementedintomedicalhomemodels.Thesehealthprofessionalscanbelicensedorunlicensedstaff,dependingontheirfocus.Ingeneral,highereducationalpreparationispreferredforpopulationmanagementofcomplexillnesses.

Intheoutpatientsettingtherehasbeenanexpansionofdutiesforpharmacists,nutritionists,socialworkersandmedicalassistants.Technologyhasmadethedelegationoffunctions–suchasvitalsignmonitoring,glucose,andotherlabchecks–easier.Onecommunityhospitaladoptedacurriculumforthemedicalassistantrolefromateachinghospitalmodel.Thisenabledthemtoadaptthesemodelsandnothaveto“reinventthewheel.”

Asworkloaddemandsincreaseforcasemanagers,someorganizationsareprovidingsupportroles(e.g.bachelor‐preparedsocialworkers)todomoreroutinedischargeplanning.Thisallowscasemanagerstospendmoretimeoncomplexcases,patientsandfamilies,andwithotherteammembers.Additionally,entry‐levelserviceroleswereidentifiedtoassistwithworkloaddemands.Oneexampleoftheserolesis“constantcompanions”whichhavebeenimplementedtohelpwiththeincreasingnumberofpatientswithbehavioralandcognitiveissues.

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Anotherwaytominimizeemployedfull‐timeequivalents(FTEs)mightbetochangethenatureofpartnershipswithvendors.Servicessuchasfoodservices,housekeepingandclinicalengineeringarefrequentlyoutsourced.Withincreasingaccountabilityforthepatientexperience,costsofcare,andmaintainingcurrentknowledge,thesepartnershipscanlookmorelikeemployedrelationshipswherethestaffmaybeeligibleforrecognition,receivecommunications,orparticipateinstaffmeetingsandimprovementactivities.

Otherrolesdescribedwereprojectmanagersinnon‐clinicalandclinicalareasforfunctionsthatdonotfallwithintypicalclinicalservicelines,suchasdiabetesmanagement,palliativecareorspace/facilityplanningspecialists.Successwiththeseroleswasdescribedas“evolving.”Someintervieweessharedconcernsthatnotenoughattentionisplacedonintegratingrolesintoexistingpatientcaredeliveryteams.“Frequentlyotherpeopleontheteamdon’tunderstandanewroleandcomewiththeirownexpectationsofwhatthatpersonshoulddo.”Attimesnewrolesweredescribedasfragmentingcareandslowingthingsdown.Therecognitionthatthedeliveryofhealthcareiscomplexandrequiresateameffortisnotnew.”It’sjusthardtoputcoordinationintopracticewiththepaceweworkateveryday,”commentedonenurseleader.Itappearedthatmanyofthehospitalshadnotdevelopedcurriculum,competencies,orevaluationforteam‐basedcare.

3.Canyoutellmewhatyouthinkismosthelpfultobuildingaworkforce?Whatdoyoufindlacking(orbarriers)intransformingtheworkforce?

Theemploymentmarkethasbeenstrongsince2008whentheeconomiccrisishit.Infact,alloftheorganizationsrepresentedhadexperiencedlayoffs.Asaresult,mostvacantpositionshavehadmultipleapplicants,allowingorganizationstobeselectiveinhiring.Themostfrequentresponsetothequestionwastheexistingworkforceitself.Theaveragelengthofserviceinmanyorganizationsis15yearsorgreater.Despiteissuesaroundresistancetochange,loyalandexperiencedstaffwerethemostfrequentlycitedadvantagestotransitioningtheexistingworkforce.Theknowledgeofhowthingswork,thewillingnesstoorientandtrainnewemployees,andtheprideintheirworkwasoftendescribed,observedandcelebratedatroutineorganizationalevents.

Somehavereportedmeasureableimprovementwithinworkenvironmentsatisfactionthroughmoreemployeeengagement.ThoughsomeleadersfeltdesignationssuchasMagnetattractedandretainedstaff,theycouldnotpointtospecificevidencetoconfirmthesereports.AseniornursingleaderfromateachinghospitalwithMagnet‐designationnoted,“Formorethan10yearstherehasbeenaminimumhiringrequirementofaBSNforstaffnurses.We’vehadnoproblemattractingnurses.”

BarriersDespitesomeofthepositiveexperiences,therewerebarrierstotransformationneedsthatweredescribed.Thoseinclude:afearofdelegatingtransitiontasksofcaretoothers;newrolesnotbeingembracedbystaff;andlaborcontractlanguagethatmakesitchallengingtocreatenewroles(orexpandrolesofothers).Anexamplecitedofthelatterwastheimplementationof

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residencyprogramsfornewnurses,recommendedbytheInstituteofMedicine’sFutureofNursingReport.Oneseniornursingleaderreportedthatinordertoimplementtheresidencyrolefornurses–muchlikethemodelforphysicians–alowersalaryscalewouldneedtobeimplemented.Theorganizationhadbeenunabletoimplementtheresidencyprogrambecauseunionleaderswouldnotagreetothelowerpayscale.

Otherbarrierswerewidevariationintheunderstandingofhealthcarepolicyandreform,whichformthefoundationfornewstrategiesbeingimplemented.Onedirectorstated,“There’salotoftalkaboutinter‐professionallearning,buttherereallyisnotmuchgoingon.Muchofthecollaborationneededtodelivercaredependsonexistingrelationshipsandorganizationalculture.”

Thoughintervieweesbelievedthatphysiciansandemployeeengagementstrategiesweremakingincrementalimprovementsinwaysofworkingmoreeffectivelytogether,therewasstilla“disconnect”betweenthetopoftheorganizationandthefrontlines.Onemanagerdescribedthepositiveresultsofleanprocessimprovement,butfeltthatleanwasn’talwaysembracedbyseniorleaders.

Onedirectorstatedthatalthoughcustomerservicetrainingwasavailable,itdidn’tnecessarilyresultinstaffinnatelyfeelingcompassionorunderstandingoftheperspectiveofthepatient,familyoracolleague.Inreflectingonwhycustomerserviceprogramshavehadmixedsuccessinhospitals,oneseniorleaderstated,“Thereisanawarenessoffatigueintheworkplaceforeducationtargetedat‘fixing’thestaff.Oftenwhentherearebehavioralproblemsintheworkplace,itcomesfromfearandlackofcommunicationandunderstanding.Whenfearisthebasicmodusoperandi,it’sdifficulttoexpectchange.”

Realtransformationcomesnotfromwhatworkersaretoldtodo,buttheconsciousnesswithwhichtheydoit.Thereisvariabilityinthelevelsofawareness.Thiscontributestotheabilitytoacceleratechangeintheworkenvironmentmorethanhasbeenrecognized.Intervieweestalkedabouttheresilienceoftheworkforceas“confidenceinmanagingchange.”Ifchangemanagementprogramsarenothandledcorrectly,employeesdevelopapathytoimposedprogramsfeeling“thistooshallpass.”

4.Wheredoyoulooktohirepeoplefrom?Whattypesofpeopleorexpertisewouldyouliketohaveonstaffthatyoufeeliscurrentlymissinginorderforyourorganizationtobesuccessful?

“Wemayhaveastronghiringenvironment,butthecurrenthealthcareworkforcewaseducatedandhasworkedinamodelthatdoesn’texistanymore,”statedaseniornursingexecutive.Allbutoneoftheintervieweesdescribedstrategiestolookinternallyforworkforcetransformation.Theoneexceptionnoted:“Weliketohireentry‐levelemployeesfromindustriesthathaveplacedemphasisoncustomerservicetrainingsuchasDunkinDonutsandMcDonald’s.”

Oneorganizationreporteditsinternalstrategyistohirefromwithin;thisincludeshiringandorientingstaffwithoutspecificpositionsavailable,aswellassuccessionplanningtopromotefrom

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withintheorganization.Othereffortsincludedscreeningandinterviewingstrategiestohireforvaluesandqualitiesthatsupportteamworkandcompassion.Whatintervieweesareseekingare“teachable”staffandthewillingnesstobeflexibletochangerolesandsettings.

Theneedforbetterandmoreseamlesscareerladdersthatwillallowworkerstoretrainfordifferentsettings,servicesandpopulationswerealsoidentified.

Severaloftheintervieweesreportedchallengeswithrecruitingandretainingnursedirectorsandmanagers.Therewasconcernthattheserolesdonothavethesupportsorsalarylevelsthatwouldmakethemadesirablecareerpath.

5.Whatapproacheshavebeentakentosupporttheeducationalneedsandongoingacquisitionofnewcompetenciesintheworkforce?

Anumberofapproachesaretakentosupporttheeducationalneedsofhealthcareworkerswhoareknowledgeworkers;examplesincludeformaleducationalclasses,attendanceatoutsideconferences,andrequiringcertaincredentialsorcertificationsforthecorrespondingposition.

Timeforlearningisconsideredasignificantbarrier.Howevertheincreaseinon‐line,orinshorterintervaleducation,hasmadeitmoreattainableforstafftoparticipate.Attendingoutsideeducationthatmayteachaboutanapproachtocareadoptedatateachinghospitalisnotviewedasvaluablebythestaffinacommunityorpost‐acutesetting.Ideally,asstaffdevelopexpertise,theyvaluelearningrightonthejob.Accesstosupervisors,educatorsorclinicalspecialistsareideal,butwithbudgetcutsandwithmanagementstaffspendingmoretimeawayfromdepartments,ithasbeenachallengetomaintaintheserolesorthepresenceofmentors.

Newinformationsystemsandtheelectronicmedicalrecordhaveandwillcontinuetoconsumetrainingtimeasthesesystemsareeverchangingandregularlyupgraded.Everyinterviewee’sorganizationwasworkingwithahybridofmodelsrequiringstafftonavigatethroughdifferentsystems.Aseniorexecutivereportedthat,“Aphysiciantoldmeofacasewherehespentahalfhourwithapatientandittranslatedtothreehoursofcomputerwork.”

Simulationtrainingisbeingusedforclinicaltrainingandincreasinglyforteamtraining.

6.Howiseducation/trainingfunded?Isthefundingadequate?

Organizationsreportedvariedcommitmenttoeducationanddevelopment.Forinstance,thegoaltoattainMeaningfulUsemayresultinfundingtosupportITtraining.Mostorganizationsprovidededucationforupdatesonnewequipmentoreducationrequiredforimplementationofnewpolicies,orcredentialingandaccreditationrequirements.

Teachinghospitalsreportedmoreongoingclinicaleducationandpaidforcertifications(whichtypicallyrequiredemonstrationofongoinglearning).Outsideconferenceswerefrequently

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mentionedfornursing,physicianleadersandseniorexecutives.Withtightbudgets,mostorganizationsaretryingtoevaluatethebesteducationvalue.Seekingphilanthropydedicatedtoeducationisemergingincommunityandteachinghospitals.

7.Wheretherearegapsinprovidingforeducationalneeds,whatwouldprovidethemostvalue?

Useoftechnology.Forexample,accesstoweb‐basedtrainingwasusedbyallorganizationsrepresented.Thisallowsorganizationsnottohavetodevelopallofthecontent.

Thereisaneedformoreinter‐professionaleducation,includinguseofsimulationtechnologyandmodelsofteamtraining.

Hospitalswanttheabilitytointegratelearningwithworkimmediately.Severalorganizationsdescribedthevalueofbringingteamstogethertohelpsolvecurrentproblemswithintheirdepartments.

MaureenBisognano,CEOoftheInstituteforHealthImprovement,spokeabout“flippingeducation”inher2013keynoteaddressattheAnnualMeetingoftheInstituteforHealthcareImprovement.Theconceptofchangingthetraditionalclassroommodelwherestudentslearnthengooutandtrytoapplywhattheyhavelearnedgets“flippedwheretheybringtheir‘homework’intotheclassroomandtheteacherismoreofa‘guide’tounlockingthesolutionsfortheproblemsencountered.”

8.Whataresomeemergingareasofpatientcaredeliverythatyouthinkrequirenewskill,rolesorresponsibilities?

PopulationHealthManagement:Althoughmodelsandevolvingcertificateprogramsareoutthere,thereisstillaneededforcliniciansaswellasexecutivesthatfosterlearninganddevelopmentofevidenced‐basedpractices.

Short‐termacutecare:Thenursepractitionerroleintheinpatientsettingincludesafocusoncaremanagementandcoordination.

Datamanagement:Asmoredatabecomesavailableregardingoutcomes,itneedstobereportedinatimelyandunderstandablemannertoallowtheteamtotakeaction.Dataspecialistsembeddedinclinicalteamswouldimprovethisarea.

Navigatorstoworkdirectlywithspecificpatientpopulationsandassistthemwithcaremanagement.

Leadershipinatransformingenvironment:Theroleofleaders–fromseniorexecutivestofrontlinesupervisors–ischangingrapidly.Thereisrecognitionbyintervieweesofthebarrierspresentedbythehierarchy.Theconceptof“teamintelligence”wasdiscussed.ThisisdefinedbySuzanneGordon,authorandjournalistwhohasstudiedhospital

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environments,as“Theactivecapacityofindividualmembersofateamtolearn,teach,communicate,reasonandthinktogether,irrespectiveofpositioninanyhierarchy,intheserviceofrealizingsharedgoalsandasharedmission.”Intervieweesnotedtheneedforleadershiptorecognizeandsupportcapacityforteamlearningintheirorganizations.Thisultimatelyresultsinlessdependenceonhierarchyforproblemsolving.Otherexamplesfocusedoncreatingmoreconnectionbetweenleadersandfrontlineworkers,throughinitiativeslikeleanprocessimprovementandregular“rounding”indepartments.

IV. SURVEY

Thepurposeofthesurveywasto:

1. Identifypriorityknowledge,trainingandeducationneedsinthehospitalworkplacenowandoverthenextthreeyears;

2. Identifybestpracticesforaccessingeducationandhighestvaluepointforthelearner;

3. IdentifywaysMHAcancontributetosupportingmembers’workforcetransformationneeds.

Thesurveywasdistributedelectronicallyto5,187individualsfromthemembershipdatabase.ItwasavailablebetweenMay15toJune1,2014.Therewere438responsesforan8%returnrate.

SurveyresultsRespondents

Thefollowingchartshowsthebreakdownoftherolesofthe438respondents:

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Thefollowingchartshowsthebreakdownofthetypeofhospital(teachingorcommunityhospital)orpracticegroup.

Therespondentsrankedthetopareasthattheyseeasareasofeducationneeded.Theareastheyidentifiedinrankorder:

1. CreatingEngagementBetweenPatients&Staff

2. CMS/HealthcareRegulationUpdates

3. LeadershipDevelopment

4. ChangeManagement

5. DataAnalysisandManagementSkills

6. ConflictManagement

7. EmergingTrendsinHealthcare

8. HealthcareTechnologyTrendsandPracticalApplications

9. EffectiveCommunication

10. BuildingResilienceintheWorkforce

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Togetasenseofperceivedstaffingissueswithintheorganization,weaskedrespondentstoindicatethetopthreepositionsthattheirorganizationneedstofill.Table3showstheirtopfourrankings:

Weaskedrespondentstoindicatetheirlevelofcomfortwiththeknowledgetheyhaveinanumberofareas.Belowarethetop3areastheyindicatedthemostdiscomfort,with#1beingtheareawiththemostdiscomfort:

1. Emergingtechnologyandbiomedicaldevices

2. Behavioralhealthmanagement

3. Populationhealthmanagement

Weaskedmemberstoranktheareastheyarepersonallymostinterestedinmoreeducation:

10.75 

8.75

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Inmovingawayfromhowrespondentsperceivedtheirownknowledgeneeds,weaskedabouthowlearningneedsareviewedfortheorganizationasawhole.Thetop6outof20areasofperceivedorganizationalneedforknowledgewere:

1. Buildingaresilientworkforce2. Stressmanagement3. Changemanagement4. Leadershipinatransformingenvironment5. Datamanagementanduse6. Populationhealthmanagement

Note:Thedatashowtherespondentsseetheneedsoftheorganizationdifferentlyfromtheirownneeds–e.g.,lowneedforchangemanagementskillsforindividual,buthighneedidentifiedattheorganizationallevel.Thereisahigherrankingofimportanceofskillatmanagingthecontextforreformovernewtechnicalorclinicalskillsets.Theprioritizationisfortheorganizationtoaddressstress,buildingaresilientworkforce(definedattheabilityoftheworkforcetodealwithconflictandchange,andtodevelopleaderswithtransformationalskills.

Weaskedrespondents“howpreparedorunprepared”theirorganizationiscurrentlytomeettheemerginghealthcareneedsoftheircommunity.

94.19%ofrespondentsfeltthattheirorganizationwas“prepared”,“wellprepared”or“verywellprepared.”Weaskedrespondentswhatarethebarriersforkeepingupwithhealthcaretrends.

0

10

20

30

40

50

Lack of Time Budget Constraints Other

Percent

Barriers

Largest Barriers for Keeping Up with 

Healthcare Trend

31.72

Note:LackoftimeandBudgetRestraintsmadeupnearly75%oftherankingofbarrierstokeepingupwithhealthcaretrends.

43.22 

25.06 

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Weaskedrespondentstoreplytothisstatement:Iunderstandhowmyjobisrelatedtothemissionandpurposeofmyorganization.

Note:0%said“don’tknow/notsure”Thismayreflecttheemphasisoverthepastdecadeonthepatientexperience,customerservice,importanceofteamwork,introductionofprocessimprovementteams,rootcauseanalysis,andassuringthatemployeesareknowledgeableregardingthemissionandvisionofthehospital.

Weaskedrespondentstoreplytothisstatement:IhavetheknowledgeIneedtodomyjobright.

76.33 

88.16 

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Weaskedrespondentsaboutthegenerallevelofsatisfactionwithresourcesprovidedforeducationintheirorganization:

Methodsoftrainingpreferredareindicatedbelow.Hybridtrainingwasidentifiedbyfarasthemostpreferred.

Percent

53

14.98

14.52

13.36

4.14

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Preferencesforlengthoftraining:

Note:Lessthan7%preferredamulti‐daytrainingsession

V. SUMMARYOFFINDINGS

Apictureemergesofaworkforcethatunderstandstheeffortsandstrategicchangestheirorganizationsaremakingtorespondtohealthcarereform.Therespondentsalsoreportfeelingahighdegreeofconnectiontotheorganization’smission.However,thedegreeofconflictandstresswithintheorganizationandlearningacrossteamsappearstobeundergoingsignificantchallenges.

Respondentsprefertousetheirlimitedtimeonlearning–specificallythatwhichdirectlyappliestotheknowledgeneededfortheirroles.Thislearningshouldbedeliveredinwaysthatresultinaddingvaluetothoseissueswithwhichtheyarecurrentlystruggling.Theapproachtolearningmaydifferdependingonthetopic.Forexample,learningtoworkasateamisnotconducivetowebinarformat.Inter‐professionallearningdoneinanenvironmentthatisnotviewedasrelevanttoanindividual’sworkenvironmentmaynothaveaddedvalueeither.

Thesurveydemonstratesthatworkforcetransformationmustbedoneinsuchawayastoaddvaluetotheorganizationandtheindividual.Ashealthcarechangesfromavolumetoavalueproposition,somusttheapproachtothedevelopmentoftheworkforce.Understandingofroles,teamlearning,andindividualresiliencearethefoundationfortransformingthecurrentworkforce.Responsessuggestthatiftheenvironmentissupportedcorrectly,thestaffitselfwillengageinawaytoassuretheirlearningneedsaremetinwhatismorelikelytobeamoreproductive,efficientandrewardingmanner.

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VI. WEAKNESS/BIASESANDLIMITATIONS

ThesurveyandassessmentwasaninitialinquiryintothedynamicspresentinMHAmemberorganizations.Theconditionofanonymitywasimportanttosupportingtheauthenticityoftheinformationobtained.Theapproachofexaminingconcurrentqualitativewithquantitativedataisidealbutmaynotdirectlycorrelate.Theassessmentofworkforcetransformationneedswasobtainedfromtheopinionsofabroadrepresentationofindividualsinhealthcare.Thisservesasastartingpointforthereinforcingandrestrainingforcesofchangeandultimatelyapathtosupportthehealthcareworkforcetransformation.Nopatientsorfamiliesparticipatedinthesurvey.

Therewassignificantemphasisanddiscussionregardingtheroleofnursinginthecontextofhealthcarereform.Thismayreflectthenumberofnursesinterviewed;however,literaturesupportedtheirperceptions.Theimportanceoftheinterdisciplinaryteamandnewrolesemergingarerecognizedandthereisanevolvingunderstandingofthenursingvaluepropositionisalsogainingfocus.Additionalstudyandreferencesincludedinthisreportpointtoopportunitiestolookwideranddeeperintootherteamrolesandskillsets.

VII. CONCLUSIONSHealthcareexpendituresaccountforasignificantpercentageofthenationalandstateeconomiesandcontinuetogrow.HealthcareorganizationsinMassachusettsandtheirworkforcesareincreasinglystrainedasmorepeopleenterthehealthcaresystemasaresultofcoverageexpansion,demandingnewapproachestocaredelivery.Itiswidelyrecognizedthatdevelopingandsupportingaproductiveworkforceisessentialtoloweringper‐capitacostsofcare.Itistimetoexpandonhowtoalignpaymentsystemsandnewmodelsofcarewithhowtotransformthehealthcareworkforceinordertodelivernewmodelsofcare.

WeappeartobefortunateinMassachusettsthatwithinourhealthcareorganizationsthereisanappreciationfortheworkforce’sknowledge,loyalty,andprideinwhattheydo.Itisthereforealsoimportanttolookcloselyatthestrengthsoftheworkforce.Thesurveyrespondentsreportstrongbeliefintheirhospitalsandfeelingconnectedtothemission.However,theunprecedentedchallengeofretoolingthecurrentworkforceforthepresentandforeseeablecircumstancespresentslargerbarrierstoremodelingeffectivecaredelivery.

Earlyadoptersarepilotingnewroleswhichareintendedtogivegreaterattentiontoteam‐baseddeliveryofcareandaccountabilityforoutcomes.Teamtrainingeffortsareintheirearlystages.Thereissignificantfocusontheroleofnursingasanextpointoffocus.Aswithallearlyinnovations,therearelessonstobelearned,improvementstobuildupon,andknowledgetodisseminate.However,thereareconsiderableculturalbarrierstochangingtheworkforce.It’simportanttonotethatlackofprogressonawidescale‐change,however,willcomeatagreatcostoflimitedproductivitythatisalreadyata20‐yearlow.Theburdenofthatcostcouldsignificantlyobstructtheabilitytomakeadvancementsintheredesignofcaredelivery.

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Engagementoffrontlineworkersiscriticalinordertoconnectstrategicvisionwithexecution.Mosthealthcareworkershaveimportantideasforimprovinghealthcaredelivery.Itisunderstoodthatfixed,layered,fragmentedapproachestoanywork,butespeciallycomplexworkwheretherearefrequentdecisionpoints,requirespeopleandteamsworkingwithintelligence.Thenew“teamintelligence”developswithafoundationofaresilientworkforceenergizedbypossibilityinsteadoffear,understandinginsteadofconfusion,andauthoritythatcomeswithownership.Clearandongoingcommunicationbetweenleadershipandthefrontlinesiscritical.

Healthsystemchangewillrequireaworkforcewithroleandcareerflexibility.Leadersandworkersneedtoshiftfromrigidroleandtaskorientationtowelldefinedcareerframeworksthatprovideflexibilitytochangerolesandsettings,developnewcapabilitiesandalterprofessionalfocusinresponsetothechangingenvironmentandtheneedsofpatients.Laborunionswillalsoneedtobringanewvisionofpotentialtowhatwillcreatecareerlongevityandopportunityandworkwithhospitalstocreatenewandmoreflexiblestructures.

Startwiththequestion:Whatdoesthepatientneed?Manyoftheintervieweesusedexamplesofcomplexcarejourneyswithfamilymembers.Byretoolingtheworkforceandacknowledgingpatientstories,staffwillbeabletocreateidealjourneysthatincludethepatientandfamilyperspective.Knowingthepatient,integratingcareandmanagingtransitionsbetweenhome,outpatient,andacutesettingsiscriticaltodefineandtrainasateam,evaluatingresultsfromthepatientperspective.

Movingaheadandreframingsubsequentquestions:Asgreaterunderstandingisacquiredarounddiseasemanagement,carecoordination,andpatientneedsthenextstepistoposemorequestions:

‐ Doestheworkforcehavetherightskillsandcompetenciesneededtofunctioninnewmodelsofcare?

‐ Whatrolesareneededandhowcandifferentskillconfigurationsbestmeettheseneedsindifferentgeographiesandpracticesettings?

Importantconsiderationstomovingahead:

Afocusonhavingfewerteammembersaroundasmallerpopulationofpatients. Trainingindividualsfornewroleswitheducationandtrainingthatisconvenient,timely,andwithfinancialincentivesthataretakenintoconsideration.

Trainingteamstoacceptnewroles;otherteammembersneedtounderstandthecontentofnewrolesandfeeltheindividualisappropriatelytrainedtotakeonthenewrole.Theyalsoneedtounderstandhowthenewrolefitsintoworkflowandoverlapswiththeircurrentrole.

Attentiontoindividualresilienceandvitality:educatingprovidersandsupportingworkenvironmentsthatvalueself‐care,reflection,andrespectwillpromotecreativity,innovation,andcompassion.

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Leadershipcommitmenttoresourcingworkforcetransformationincludingthedevelopmentandsupportfortransformationalleadershipskillsandstandardizingtheirownworktopartnerwithfrontlineworkers.

Applyfocustoredesigningcurriculumforstudentsinthepipelinetoincludenewsettingsforeducationandexposuretorolesandaccountabilityforcare.

Itwilltakeaconsistentcommitmentofresourcestoachievetheretoolingofthecurrentworkforceduringachallengingtimeforhealthcare.Considerationsfornewwaysoffundingorpartneringwithotherorganizationwillneedtobeconsidered.Thisfundingwillnotbejustorganizationbased,butshouldbeaimedatsupportingwidescalechange.

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ACKNOWLEDGEMENTS

Deepappreciationmustbeextendedtothe16individualswhorepresentedfrontlinestaff,mangers,directors,seniorleadersandhospitalCEO’swhomadethemselvesavailablefortheinterviews.Theircandorandpersonalcommitmenttounderstandingandaddressingtheneedsoftheworkforcewasevident.

SeveralotherleadersprovidedperspectiveforthisreportrepresentingtwoorganizationsthatservetoleadchangeinhealthcareinMassachusettsandbeyond:SharonGale,CEO,OrganizationofNurseLeadersofMassachusettsandRhodeIslandandJoanneHealy,SeniorVicePresident,EducationandDevelopmentfortheInstituteforHealthcareImprovement.

TheGallupCompanywasengagedforassistancewiththestructuredinterviewquestionsandsurveydesign.However,itsstaffwentwellaboveandbeyondtheirscopebyaccessingsupportfromtheirconsiderablytalentedteaminordertoproducemeaningfulinformation.

Andlastly,thestaffoftheMassachusettsHospitalAssociationwhosespecificjobitistounderstandthelearningandeducationneedsofthosewhoareresponsibleforfuturecaredeliveryandwhoaremakingourhospitalsandhealthsystemsthesafest,bestexperienceforallpatientsandfamilies.RecognitiongoesespeciallytoPatNoga,RN,PhD,VicePresident,ClinicalAffairs;KirstenSingleton,CAE,ExecutiveDirector,CenterforEducation&ProfessionalDevelopment;andJillEttori,Marketing&EventsSpecialist.LynnNicholas,FACHE,CEO,championedtheapplicationforfundingforthisreportsothattheconversationaboutworkforceneedscouldbeelevatedknowingthepowerofcollectivethoughtandcollaborationthroughouttheCommonwealth.

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REFERENCEDINFORMATIONALSOURCESANDRECOMMENDEDARTICLES

Porter,MichaelE.andLee,ThomasH.“TheStrategyThatWillFixHealthCare;providersmustleadthewayinmakingvaluetheoverarchinggoal.”HarvardBusinessReview,October2013.“Team‐Basedcompetencies;BuildingaSharedFoundationForEducationandclinicalPractice,RobertWoodJohnson,ConferenceProceedings,February16‐17,2011,WashingtonD.C.“WorkforceRolesinaRedesignedPrimaryCareModel”AmericanHospitalAssociationRoundtable,2011.“ReconfiguringtheBedsideCareTeamoftheFuture.”AmericanHospitalAssociation,Roundtable,2014.“RedesigningtheCareTeam;TheCriticalroleofFrontlineWorkersandModelsforSuccess.”EngelbergCenterforHealthCareReformatBrookings.March014Gordon,Suzanne,Mendenhall,PatrickandO’Connor,BonnieBlairBeyondthechecklist;WhatElseHealthCareCanLearnfromAviationTeamworkandSafety.IRLPress2013.Swenson,S,Pugh,M.McMullan,C.,KabcenellA.HighImpactLeadership:Improvecare,ImprovetheHealthofPopulations,andReduceCosts.”IHIWhitePaper,Cambridge,MA:InstituteforHealthcareImprovement;2013.CriticalRoles:California’sAlliedHealthWorkforceFollowUpReport,CaliforniaHospitalAssociation,March2014.InstituteofMedicineoftheNationalAcademies.TheFutureofNursing:LeadingChange,AdvancingHealth.ReportBrief.October2010Kocher,Robert,MDandSahni,NikhilR.“RethinkingHealthcareLabor,NewEnglandJournalofMedicine365:15October13,2011.