Dani:

Welcome to the Handoff from Trusted Health. I'm Dr. Dani Bowie. Today, I have the pleasure of speaking with Dr. Aries Limbaga, the CEO of Rancho Amigos National Rehabilitation Center, and the System CNO for their health system. Aries has a fascinating journey, beginning as a student nurse and eventually taking on leadership roles in healthcare management. In our conversation we'll discuss the challenges and opportunities in nursing, the importance of flexibility and how technology is revolutionizing staffing solutions. So join us as we delve into Aries' inspiring story, his passion for serving marginalized populations and his insights on the future of nursing. Dr. Limbaga, welcome to the handoff.

Aries:

Thanks, Dani. Happy to be here.

Dani:

We're really excited. I'm excited to share your story with our listeners. You know, it'd be really great to help our listeners understand just a bit of your background as well as your current role at DHS, LA County, and what you do today.

Aries:

Currently, I'm the CEO for Rancho Amigos National Rehabilitation Center, and also the system chief nursing officer for our health system. So I oversee, uh, the nursing services for our four hospitals, our 28 health centers, and our correction health services. I actually started in our system as a student nurse, uh, back in the mid nineties. So I was finishing up my BSN and my last year, my BSN I, uh, was introduced to, to Rancho as a student nurse and kind of fell in love with the population that we were serving and, and have been, uh, with the organization since. So over my last, uh, 20 plus years, you know, I was, uh, a bedside nurse, an assistant nurse manager, clinical director, chief nursing officer, and then about four, I think about four years ago became the CEO of our current hospital. And two years ago I took on the additional role, um, system chief nursing officer. So it's been a lot of fight and a lot of work.

Dani:

Yeah, I would say sounds like, you know, a lot of different, you know, all facets of DHS from the years of experience you've had there and the journey of your career and different roles, uh, you know, you have a really unique background in that I have yet to meet many leaders who are both the system CNO of a health system, as well as carrying the CEO title of a hospital. It sounds like a lot of work, and I'm really thankful you're meeting with us today and you're, you're giving us some of your time. I'm curious to understand how there may be some synergy between the two roles, but also if you've experienced some tension or how you manage kind of both hats today and do so with keeping, you know, patient care at top of mind as well as the nursing profession and all the other responsibilities as CNO.

Aries:

It is definitely not something I would recommend un unless you have, uh, really been in a system a pretty extensive amount of time. And so I was lucky enough in this CEO role that I started here as a, as a student nurse worker and essentially managed, uh, most of our departments except for our finance team and our, and our physician team. Um, but everything else I was able to really oversee and run through my 20 plus years. So the hospital role, I really have a good sense of knowledge, um, around the day-to-day operations, the system role. Because I was a previous CNO I had a good understanding of nursing operations as well. So I took that into that system role. Given both roles, there have been tension between both roles, you know, you know, with the CEO role, very much day-to-day operations of the hospital, you know, looking at our strategic priorities for the organization and for the hospital, and meeting those, those needs.

With the system role, it's really focusing on system nursing practice, the standardization of that practice, how are we optimizing our nurses in the system. So very two different roles, uh, but there is some synergy between those two roles. And I think that synergy is that I'm able to really leverage what I know as a facility, CEO, with the system CNO role, so that we are really looking at things from both lenses from a nursing standpoint and from a, uh, facility CEO standpoint, uh, and creating value from our me sync functions in the facility and in the organization.

Dani:

What advice would you give to our listeners? So, you know, we have lots of listeners in different capacities in healthcare, and some may be thinking, you know, CNO role is right for me and I wanna go down that path, or CEO role sounds really interesting. I wanna go down that path or even a system role, since you've done all of it. Is there any advice that you would give to our listeners that you felt like was helpful for you as you went down those different paths that you would encourage our listeners to consider in preparation for some of those roles?

Aries:

One of the things that I, I have learned was to not be comfortable, right? Always try to achieve that uncomfortability, right? Because I think every project I've taken on, I've been like, Hmm, that's different. Let me see what I can do. And it's been really a great for me to, to learn, right? And to step up onto projects that others would say no to. And I think that's really important is to challenge yourself. That is key. And not to limit your opportunities. I, I did not think about the CEO role, um, at all. And then I was approached when our CEO left to take on a larger role at one of our other hospitals to take on that interim role for about six months. And then I decided to actually apply six months in saying, you know what? I actually like this role. Um, I like the ability to, you know, influence at this level and being able to work with my peers. Um, it was really enjoyable and be able to show that impact. Not sure a nursing standpoint, but from a hospital and patient population standpoint,

Dani:

That's really good advice. You know, uh, be open to new opportunities, uh, maybe take on work and roles that you wouldn't have in the past or join projects to get that exposure. And then what I'm hearing you say too is you kind of, you were given the interim moments to test it out too and see is this really a right fit for me? And, you know, where does your passion lie? So thank you for giving us some insight into that. I have asked those questions myself, and I'm sure many listening also asked those questions. What drew you to public health and what has it been like working for the country's second largest municipal health system?

Aries:

A as you know, Dani, I came into this system as a student nurse worker, so I didn't really have an idea of what, you know, what is working for quote unquote the county. Like, you know, is it like the for-profit is like a nonprofit, so none of that. Um, and so when I came into the system, I really fell in love with the population that we, we served. And, you know, as a person who immigrated into this country, um, several years ago, I really saw the population that we serve as really people that I see every day. You know, 50% of the patients that we see are non-English speaking. Um, 80% of the persons that we serve are are persons of color. And so I really identified with this population, uh, we also serve, uh, mostly Medicaid type of population, so look lower socioeconomic status. And as you know, Rancho primarily caters to individuals with disabilities. So really that trifecta persons with color, uh, persons with disabilities and those with more socioeconomic status. So that really spoke to me and really, this is where I felt I would do the best service. Um, so that's why I fell in love with working for the county, and that's why I'm here today.

Dani:

I love it, you know, mission driven and also this really unique perspective that you have with immigrating into the states and identifying and having that story and journey. And I think probably a broader sense of awareness and compassion for that population. Uh, this's just a really cool story and journey, um, and ways that you've been able to serve. You know, I wanna talk a bit more now about flexibility in the future of nursing, and that's been our primary focus of season seven is, you know, looking at current state, thinking about the future. Flexibility is a hot topic. I'm seeing it everywhere. Um, and so I, I just wanna understand from your perspective how d h s is thinking about staffing and flexibility and, you know, what are some new programs or initiatives that you're implementing at D h s?

Aries:

You know, this is a tough question because, you know, nursing is not known for its flexibility, right? We have a very rigid staffing model, and I know when I was a bedside nurse and when I was a assistant nurse manager, you know, our schedules were set six weeks in advance, don't touch the schedule because you're, you're gonna mess up our, our our staffing, right? And so with six months in advance, you'd have to have a nurse would sign, you know, a piece of paper, ask them for a day off, and then the manager would have to figure out, okay, what, you know, if they could grant it or not. And so it was a very rigid staffing model, and so we really needed to look at, you know, how do we create a staffing model that creates flexibility in the workforce, but also allows us to really allow the managers to do more than staffing, right? So many of our managers spend so much time just staffing their unit, um, and there's so much more to being a manager than than staffing. So we've been looking at creating, uh, a new staffing model, um, and using new technology solutions that will really create a much more flexible and nimble staffing model for us. And so leveraging technology to do that for our four hospitals is our current project.

Dani:

That's a big project, but I'm happy to hear that you're doing it. Staffing and scheduling technology is a passion of mine. I think it's the one of the biggest foundations in creating that flexibility, but also analytics for the workforce and how to start to build in more of your strategic plan. What advice would you give to listeners and nurse executives who are thinking about flexible models, but also the incorporation of technology heads? So what have you been your learning so far through this project and maybe some of your pain points and any, you know, guidance and advice for our listeners around that?

Aries:

Sure. So, you know, this project to implement this, uh, staffing and scheduling solution, um, has been in the works for probably about two or three years, but really implementation started last year for us. I came in kind of mid-cycle, it already had started, and then I took on, uh, the, uh, system CNO role. And I remember when we implemented our E M R several years ago and how intense that work was, and I actually, I almost feel like this work is actually, uh, even more intense because it has such broader implications for the organization, right? Because with a staffing and scheduling solution, you are involved in your human resources team, your nursing informatics team, time and payroll, and all the rules related to payroll. You know, California has very, uh, extensive labor laws, and so making sure that we are integrating all of that has been challenging.

And so I would really recommend that when you are implementing these staffing solutions that you really are, are robust in terms of a, a staffing structure that support staff from a technology standpoint, from a nursing resource standpoint, and from a, from an HR and ancillary, uh, component, I think that's gonna be really key. And really the organization needs to treat this as, you know, one of the top two or three priorities in the organization and resources appropriately, because it does require a lot of bandwidth to be able to do it. So I would say that is key is creating the bandwidth to do this type of work and in ensuring too that you've got alignment from those key stakeholders that are really going to be key to the success of this implementation.

Dani:

Yeah, it again, music to my ears here and how you're approaching this project. I have, uh, led and implemented, uh, few in my time as well, and uh, it definitely created some gray hairs and a little bit of PTSD, but also the work is worth it. Uh, it is resource intensive and getting prioritization. I think that this is not just, you bring in a technology and it fixes it, but focusing on the project and implementing and building, right, so that you can sustain for the future.

Aries:

Yeah, absolutely. And I think, you know, it's, it's key. We, we don't have an option. We, we've gotta create that flexibility in nursing, you know, as you know, nursing has been, is an aging workforce and we've got a good chunk of individuals retiring, right? Our, our baby boomers are moving into your retirement. We've got Zoomers coming in, right? We've got our millennials in there and we've got our Gen Xes in there. And as you know, like as you move down those generations, you know, flexibility becomes more and more key. And I think if you don't create a staffing solution that allows for that flexibility, you're, you're not gonna have the workhorse there that you need to take care of your patients.

Dani:

Putting flexibility top of mind and, uh, you know, engaging your workforce where they're at, recognizing, hey, there's different needs, uh, as the nurse journeys through their career, I think is a key, key thing. You know, what is DHS doing also to attract and retain nurses? So we're talking about flexibility, but I'd love to know what type of programs you have in place to also continue to build your pipeline, uh, support the existing workforce that you do have.

Aries:

A key element in attracting nurses, I think is really trying to identify organization fit. I think that's, for us, that's first and foremost because of the population that we serve. It is a more complex population, and so looking for individuals that want to really work with that population is key. So that's number one. What we've also seen too is that because, you know, many of our nurses who are retiring is really a major issue for us, right? Because we're losing that talent to retirement. And that's typically what we've seen in our organization is mostly we're losing folks to retirement versus losing them to other organizations. Um, so when we're losing them to retirement, they're being replaced by essentially, uh, mostly new graduates. And so we've created residency programs to really, uh, support our, our nurses in their training. So we've got residency programs in med surg.

We're ha developing that in critical care, um, in our perioperative suite. So that I think is helping us recruit nurses and, and they really, our goal there too then is the retention component. And I think that is also key components. How are you really trying to approve that practice environment or those nurses and you know, whether that's through, you know, appropriate support structures like clerks lift teams or nursing at attendants or, um, you know, even, uh, E M R optimization. You know, I think that is really key is really one is supporting that recruitment process, but then really what environment can you create to ensure that you've got that retention,

Dani:

The environment. And I like how you mentioned environment in regards to some support structures for nursing. Uh, you hit on some key topics that are burdened. So the, the charting burden is a real one for our profession and optimization of the E M R and, and allowing nurses to document what's been done, but maintain connections with patients and that's why we entered the profession is awesome to hear. And then lift teams support structures around that. Uh, you know, it kind of leads me to another question or curiosity that I have. You mentioned practicing in the state of California and how it's complex. You're doing this transition of staffing and scheduling and you need to be mindful of California rules and, and labor laws, et cetera. I also know that California is a state that has a staffing ratio and the only one in the country to have a staffing ratio. Other states have variation of some type of staffing law. And how has that been for you as a leader in living in the space of, or staffing outcomes? And what's been your take on operating in that space?

Aries:

So we've had state staffing ratios here, I think probably what, 20, 20 years now. Um, and I was, I remember I was a nurse manager when the ratio started and I was infused with some additional dollars so that I can meet those ratios. So I was like, yay, this is great. Uh, because I can hire some more nurses From that standpoint, it, it was great because I was able to get the resources so that I can properly staff my unit. That was good. The, the issue was that, you know, with those additional resources, some of the support structures that were removed, right, because we added the RNs, some of the LDNs and nursing intended positions were reduced to be able to kind of offset that. So in, in some ways it, it limited some of our, our flexibility. Um, but overall it, it, it's actually been quite helpful.

It's really helped us improve some of our patient safety and our clinical outcomes. It's allowed our nurses to spend more time, uh, with our, with our patients at the bedside. Uh, it's improved some of our communication a as well because you've got a, a smaller group of, uh, nurses ha doing handoff reports. So overall it, it's been good. Um, but it ha uh, has limited some flexibility for us. But I still think the key driver is really the acuity component. You know, the ratios really give us kind of the guardrails, but really the acuity levels, what really should we should be using to help us load balance our staff and appropriately staff our units.

Dani:

I think that's a really good call out. Uh, that it, it gave you the guardrails to operate within the context of some numbers or standards, but yet the ability to overlay the true staffing story patient condition, a nurse skill and ability marrying the two, and often allowing us to speak to why did we staff higher? Or maybe, I mean, in your instance in the state you can't staff less, but when I've led teams, I would say staff up or down because it's not just a number, it's the whole condition that we're taking into consideration. And so patient acuity systems and tools are really helpful. Uh, again, you're, you're doing some really great work and comprehensive work with your whole systems that you're bringing in place. I wanna talk a bit more also about your perspective as a nurse leader around flexibility. We've talked a lot about flexibility, but I have been asking all of my guests on this season, from your perspective as a nurse and a nurse leader, what does flexibility mean to you? And then elaborate any more on what it means to the nurses that you serve today in ways that maybe you haven't touched on before, just reiterating what you already have shared with our listeners today.

Aries:

Sure, absolutely. I think flexibility for us as leaders may mean something else to our nurses at the bedside, right? So for example, when I was a nurse manager, you know, flexibility me, to me, me, I was able to give you a day off. I was able to grant your vacation request. Like that to me was flexibility. But what I'm hearing now from some of our staff is that flexibility needs to be much more real time, right? So, hey, I've got something happening tomorrow. Uh, can I swap with someone tomorrow? Um, hey, can I work evenings instead of days today? Um, so that I can take care of this issue. To me, the flexibility really has to be where we meet the nurses at, right? So what is it that our bedside nurses are asking for and how do we create flexibility around that that sure, that still ensures safe and appropriate staffing and consistent staffing so that we're taking care of our patients. And that's our challenge as, as leaders, is how do we create that, that nimbleness in our scheduling? And the only way I think you can really do that is through technology that allows you to quote unquote Uberized. We are staffing and scheduling

Dani:

Gig workforce. Uberization have been trending topics as well around flexibility. So I love that you mentioned that. And I, I, you know, that's one of the passions that I have as well as a leader and also thinking about technology. And we have some great tech here at Trusted, where we are looking at that flexibility and nimbleness to respond more dynamically, particularly in the space of staffing. Cuz you, as you think about scheduling and staffing, scheduling is building a schedule. And then you get into the day of staffing and as you mentioned, life changes, right? People have things going on, uh, patient condition changes. And so how do you dynamically respond in those moments to meet the needs of the patient, but also the workforce and what they're looking for. Uh, Dr. Liga, this has been really impactful and insightful and thank you for your time. Like I mentioned, you are carrying two crew roles, two high level roles, and you still have given time to talk with me and share more of your insights around d h s and how you're leading, uh, those nurses into the future. What would you like to hand off to our listeners today as a final piece of advice or wisdom?

Aries:

You know, I think the last couple of years have been really, they've been tough on nursing, right? Uh, nursing workforce, nursing leaders. And so what I would say is, and my challenge to us as nursing leaders is how do we support our nurses that are at the bedside? You know, uh, that group of individuals have really been struggling over the last two years. There's a lot of burnout. Um, they've been la staffing struggles. And so what can we do in that space to improve that practice environment, you know, and how do we leverage technology in, in that space, either through staffing solutions, through telehealth or teles sitter, um, how do we really leverage technology to really improve that practice? Our, and I think that's really key. And second is how do we create better value propositions for our, our nursing staff that are at the bedside? And what I mean by that is, you know, nurses can help drive reductions in length of stay. They can help reduce some of our hospital acquired infections or hospital guard pressure ulcers. You know, how do we quantify that value so that we get those resources pulled down to support the, the nurses at the bedside?

Dani:

Yeah, I, I think, uh, you hit the nail on the head. How do you support the nurses at the bedside and the value prop, continue to share the, the, the value of nursing, as you mentioned, some of those outcomes. You know, some of the things I'm hearing too is like, sometimes I feel like we speak around our nurses, but you, you are a leader in the trenches with them, and so, uh, being a part of what's going on in, in their work environment and then bringing solutions is so powerful. So thank you for carrying that on for our profession, uh, and staying close to the bedside and leading from a place of, you know, being a servant leader, uh, and transformational leader. Dr. Lumbago, thank you so much for your time and I'll check back in with you in a year or so after you have implemented your staffing and scheduling solution, uh, just to learn a bit more and hopefully share a bit more with our listeners about how that went and what your great outcomes are.

Aries:

Thanks, Dani. I would love to come back and again, thanks for having me today.