Our next speaker for this afternoon's mini sessions is Dave Robbins on staffing efficiencies and challenges. Lotha, Ruth, and I thought this was an important topic for us to be reviewing at this time and we appreciate Dave's work on this. He is a fellow from MUSC in Charleston, we are identified there, and is Associate Chief and Program Director in GI at Lenox Hill Hospital and Associate Professor of Medicine at Northwell Health. Dave serves in a leadership position at the Manhattan Endoscopy Center where he is Medical Director. So, welcome, Brother Dave, and thank you for your discussion. So, I have been tasked with giving you my perspective of staffing efficiencies and challenges in 2021 and 2022, and these are really representative comments from my on the boots experience and I certainly don't have any formal training in how to resolve any of these problems. This slide summarizes my disclosures and conflicts of interest. I wish I had something to report here, but nobody is willing to pay me for my opinion, so this is effectively a blank slide. So what are your pain points? I don't want to focus on simple mechanics such as on time starts, but I want to get into, particularly during the discussion afterwards, a communal discussion about where we are hurting. And it's clear that we've experienced an exacerbation of problems with staffing, manpower, and that's impact on our workflow. And at the same time, as we struggle to fill positions, I know a lot of you are also struggling with the use of per diems and filling these slots. But I think that this problem we're facing with talent recruitment preexists this most recent pandemic, and I'll talk about some of my own insight into this, but it's been a learning curve. And then I wanted to spend a few minutes talking about employee satisfaction, and as you know, there's a tremendous amount of energy spent on patient satisfaction, and as we heard from Joe Vacari's talk, there's not a lot of effort, but increasingly some attention to physician and provider satisfaction. But when we talk about our employees in general, I think this is a neglected area still. And even more neglected probably is our sense of what they think about their employers. And if you're in a leadership position, what do they really think about you? I want to talk a little bit about staff synergy, maybe some clinical and workplace scenarios where this has been a problem. And then probably just as important as finding the right team, it's keeping the right team. And this has been a big problem for us on Madison and 44th Street, where I run a fairly large ASC, and I'm sure these are nationwide problems. And then finally, if time permits, we can talk about the difficult employee or the difficult position, but we have a dedicated talk on that coming up later as well. And Gus's talk on leadership pretty much covered what I wanted to say with one exception. So again, I want to go beyond efficiency and on-time starts. This was thought to be an oversimplification of the efficiency problem that we're facing right now. And I borrowed this from one of the quality course talks, but this looks at the reasons for delayed endoscopic procedures. And it's no surprise that 71% of the time when we look at efficiency in our own unit, the problem is actually the physician, you know, time and time again. So while patients represent the next chunk of that, you know, either with no shows or taking a long time to get dressed or come out of the changing room or they're not fully prepped, you know, the problem is one we can identify by looking in the mirror. But that's not what I really want to talk about today. I want to dive into some of these other concepts. So we talk about employee experience, and I think this relates to efficiency, but this is probably a core staffing problem. Is the recognition that our patients come and go, and of course patient care comes first, but our employees are hopefully here to stay with us. And the things that are going to make them stay are very fundamental needs. First and foremost, a sense of job satisfaction and belonging. Having dinner conversations with my mother. My mother likes to feel relevant to her children still. She's 82. She's thankfully in good health. But I get the sense that if she were to lose her sense of relevance, it would be very hard for her, in this case, as a mother, to sort of keep her job and find purpose. So we need to keep reminding our staff the good work that they're doing. Not so much for us, but I think that we're in a unique position in healthcare to remind each other that we're doing really important work for other people. And I think that's a really grounding element that sounds obvious, but I think it's good to recognize that. And then we need to keep it fun. As Joe mentioned, the work-life balance is more important than ever, but I don't have to remind you that we spend more time with our work family than with our real families. And if we're not enjoying our job, then there's going to be a high turnover and exacerbation of burnout. Promotional opportunities is interesting. When I first started working at the ASC, I didn't really have a vision of what everybody else wanted. I knew what I wanted to get out of it, but I didn't spend time thinking about what the front-end office thought they wanted to be doing, say, in five years, or what our technicians, what was their career trajectory, and on and up, nurses, and even to some extent, the physicians. My focus over the past few years has been to think about all the different employees and their roles, and where they think they're going, and how can we empower them? Because as much as we'd like to mitigate our turnover, nothing makes us happier than to promote people internally or externally, and we'll talk about that in a second. But we do go to work every day thinking there's going to be a high turnover, and certainly these past few years, we've seen an exceptional rate of turnover, almost to the point where we're used to it. But I think there are some techniques that can be used to turn the ship around. And then finally, this concept of sampling your employees and asking them what's going on, and we'll talk a little bit about radical transparency. Okay. So, are good people hard to find? Yes, I'll talk about that in a second. So maybe you found a few really great employees. Well, what will keep them? And this is really engagement. So educational opportunities are, I think, low-hanging fruit opportunities. So the American Board Certification for Gastroenterology Nurses, for example, offers a CGRN certification. This is additional training that nurses who are focusing their careers in GI can obtain. And the Society for Gastrointestinal Nurses also offers various programs throughout the year for your technicians. And this has a great impact on promotion and advancement. Okay. So we talked a little bit about educational opportunities and the fact of promotion, whether it's internal from a technician role to a nursing role, as some of our staff are going through night school, and then staff nursing, for example, being promoted to leadership roles. We recognize as an ASC that we can't compete with hospitals on many levels, and that we are a stepping stone to hospital jobs. And we're actually okay with that, but we do like to keep our staff, at least for a few years, because of the high cost of recruiting and retaining staff with high turnover. What motivates our workforce, I think, is changing during the pandemic. I'll talk a little bit about that as we're facing a national workforce shortage. But the competing opportunities were here long before the pandemic. And so whether it's a hospital job with more robust benefits and higher pay, or what I call outright poaching from neighboring ASCs, or just the need to be closer to home, or even the opportunity to work from home, these are really competitive challenges for us. And we've had staff members go into industry, for example, start working for scope repair companies or become sales associates. And while all this is okay, it's not okay if it happens all at once, and that impact is very significant. So where do you find good employees? I don't know if you guys use websites such as indeed.com or glassdoor.com, but I found some tremendous insights into our own practice by going to these websites and looking at the reviews, and I think you'll enjoy seeing that. That's coming up on my next slide. We've had some really remarkable success by advertising in pre-medical and allied health schools for positions primarily in the technician role. And I'm proud to say that over the past 10 years, we've had four staff members, one technician and three office and staff go on to medical school. So that's been really fantastic, and they've proven to be great employees for the year or two that they're with us. And we certainly found that endoscopy experience is a very accessible portal to other health care careers. And again, we're okay with that, and we have these discussions at the beginning with staff to get a sense of where they're going. Austin touched on social media in a way that I can't even hope to, but specifically when you look at how your center is viewed by potential employees, I think this is critical. And so going beyond the usual background checks for your candidates and calling your references, and I would not rely on the staff and company to do this entirely, I think you need to head to the interwebs. So what do you see on the interwebs? So in preparing for this talk, I typed in our endoscopy center, Manhattan Endoscopy, and went to indeedgut.com and found that we got about 3.5 stars out of five. And you see these categories are listed on the bottom, work-life balance, compensation, advancement opportunities, management and culture. And these are exactly the things that we've been talking about today. So these are the primary criteria by which the surveys are sent out to potential or former employees. Usually it's a former employee, so I hope you're ready for this. I'm just going to lift up the hood here. So and then the other website to go to would be Glassdoor. I didn't find much on Manhattan Endoscopy here, but these are the two primary websites. So let's go back to some of the reviews. So you'll see it's not unlike a Google review where reviews are all over the place. But I have a nurse from early this year saying this was an okay place to work, but she didn't feel like she was using her clinical skills to her highest potential, so she left. And this is unsurprising. I mean, after a few years of working in an ASC, I think it's completely reasonable to move on. However, the nurse also goes on to say the place was unorganized, and the nurse manager at the time had no clue what he was doing and was inappropriate. And nobody knew about this until about three minutes ago when I texted my office leadership to take a look at the website and see really what's going on. Ideal new grad position teaches you great basic skills for any professional nursing job. I love this. This is the idea. ASC jobs are great for new nursing students, first job, and then they usually segue on to a hospital position, and that's fine. The management really sucks. Don't waste your time. The pay sucks. The management sucks even more. Okay, so not much I can take from this other than a complaint about the way that the hallways were decorated. And then just to make me feel a little bit better before I jump out of a window, the people were really amazing. My manager was great. And I enter the room and open it to start my day. Working as a team makes the day go easily. The culture is dynamic. Okay, so there are some positives here, but I got more from five minutes of searching the web here than I have had in any of the huddles that we've had, and I think this is primarily driven by the anonymous nature of these reviews, and I think this is super important. So what is your culture? Who sets the tone? Do you even have a culture? Is there a culture? If you ask, I asked one of my physician colleagues, what's our culture? He said it's a good one. That's all I got. So it's kind of an interesting question. We talk about culture, but maybe you don't even have one, or certainly if you have one, you're not communicating it. Is it patient-centered? Is it built around quality and safety? I mean, I certainly hope that it would be, but I think this is something that you need to ask yourself, and this needs to come up in whether it's weekly or your monthly meetings, and certainly at your orientations. When you're onboarding new staff, how do you set the tone? And it's not enough to make it a passive process and assume that folks are going to understand the culture just by observing. Communication, during the pandemic, we were, well, it's still the pandemic, but during the peak of the pandemic, we were sending out very frequent emails. We thought that we did a good job of reassuring folks that even though we had to shut down for three months, that we were going to be reopening, and then I came to find out that staff don't even read their email, that the primary mode of communication was email and that it wasn't really happening. So they hadn't linked their endoscopy center email to their Gmails or whatever they use as a primary, and so this was all kind of for naught. The impact of the pandemic, I'm going to have a whole talk on this. You know, this would be a very different talk before the vaccination campaign, but new issues have certainly arisen, and it still, I think, remains to be seen whether or not the vaccine rollout and the mandates will end up being a job boost or yet another plague on top of a plague as workers who refuse to get vaccinated for whatever reason are dropping out of the workforce. I've had several concerns over the preceding 18 months about staff safety, whether staff feels safe from patients, whether patients feel safe from staff, and whether staff feels safe from staff. We're now 100% vaccinated as a unit, thankfully due to state mandates, but there was a period of time where there was a lot of suspicion among everybody about who was vaccinated. Of course, every time there's someone coughing or someone is seen without a mask on, it created a lot of strife, and this led to problems ultimately with retention. We got a little bit creative with work from home opportunities, and we tried to offsite things such as the pre-calls, the post-endoscopy calls, and billing, and allow people the opportunity to work from home whenever possible, but as you know, healthcare is primarily an in-person job. And then, of course, burnout, which Joe covered really beautifully, and I'm still recovering from Joe's talk. So where did all the workers go? I'd like to thank Scott Frazier for pointing this article. This is from Wall Street Journal. This just came out two weeks ago, and the high-level reality is that 5 million fewer employed workers than before the lockdowns, and 3 million fewer exist in the workforce altogether. And so this is a real problem, whether you're trying to hire for a restaurant or for an ASC. It's the fact that the labor pool, whether it's lifestyle choices or competing interests, it's just harder to find people. So keeping the momentum, again, I think that the communication within your staff at this point needs to be in person, and we've tried with varying success to have weekly staff meetings, but I find that even at the staff meetings, I have members, nurses, primarily technicians coming to me as the medical director saying that the nurse leadership or the office management leadership is not necessarily listening to all of their concerns, and what can I do about it? And of course, this creates a chain of command problem, and has made me think about beyond just recognition with Friday luncheons and awards and holiday parties, that in addition to holiday bonuses and ultimately a raise, maybe we need to work on this concept of radical transparency. And for those of you who are familiar with Ray Dalio's work as a founder of a hedge fund in 1993, Bridgewater, he's written a few books about this, but this concept of culture of openness and the idea that radical transparency, by basically letting everybody openly criticize, you know, constructively, hopefully, everybody else, whether you are a new receptionist or you're a senior physician, that everything is on the table. This concept of radical transparency, which I think can be slow rolled into your staff meetings, has some pros and cons. I think it's good for people to know where the pain points are in your own institution, and to know what everybody's job descriptions are, so that nobody feels like they're working harder than the next person, and that the lines of communication could not be more open. But this transparency can obviously backfire and create performance anxiety, and I'm not sure that everybody's ready for it. For example, you know, in the corporate world, does this mean that you're going to share, for example, your average salary at the center with other centers? You know, I think this is something that we struggle with on the management level, is making sure that we're competitive. But you know, whether we know it or not, the staff know what the competitive salaries are, and that's led to some very understandable poaching. So I think this is an important concept to consider, and something that we can borrow perhaps from Wall Street. So we heard about leadership. You know, we all have our leadership. Every center is different. It might be physician-centered, might be nurse leadership-centered, or maybe the primary leader at your center has an MBA, or some combination of medical degree and an MBA. But it's got to go beyond management, and as Gus pointed out, there has to be a vision. And don't forget your board. I don't know how engaged your board is, but we engage our board heavily, so much so that I think that the board wants a salary for all the work that they do. It's a volunteer position. But they're very, very much in the weeds, probably too much in the weeds, so much so that the staff will go to a board member before they'll go to nurse management or business operations. And again, I think that chain of communication needs careful attention. We've had high turnover in our nurse leadership over the decade that we've been open, and in some cases, it's very difficult for a new nurse leader, for example, to come in and inherit preexisting issues that staff have. And it's unclear to me if it's better to let disgruntled employees go and hire fresh employees. It's certainly not easy. But this is a work in progress for us. And again, this escalation policy, the idea that staff need to know who to go to, of course, there is an escalation policy if their voices are not getting heard. But if you're not even having the team meetings in the first place, or if you as a physician leader or nurse leader are leaving it to the individual groups, the technicians and the nurses, for example, to have their own huddles, that's going to lead to a lot of strife. So maybe during the Q&A, we can talk about some challenging scenarios, whether it's clicks that exist in your ASC, remind me sort of of high school, you know, or you've got certain bad actors, a disruptive employee, or I know it sounds like a unicorn, but the difficult physician that no one wants to work with. I do have technicians who almost refuse to work with certain physicians, and this creates a problem. So we need to figure out a way to counsel that physician and get past the problems. And again, this radical transparency might be a pathway to do that when all else fails. But it's clear that it's hard to deal with a difficult patient, but it's even harder to deal with a fellow co-worker who's creating problems, and this disgruntled state leads to inefficiency and overtime and a huge impact on morale. So I will leave you with that. I want to just provide some topics for discussion. I think we'll get into it during the Q&A, and I thank you for your time.

staffing efficiencies

healthcare

talent recruitment

employee satisfaction

staff synergy

retaining the right team