Dan:
Deborah, welcome to the show.

Deborah:
Thank you, happy to be here.

Dan:
Deborah, you have a non-traditional nursing role, which is a nurse in finance. We don't see much of that. In fact, you're the only one I know. Well, KT Waxman I know as well, she teaches finance, but how did you get interested in the financial aspects of healthcare and how did you leverage your nursing expertise in that area?

Deborah:
When I decided to go to graduate school, I live in New York City and Columbia University offered a combined master's that was called the nurse executive track. Basically, it was professors from the school of nursing and professors from the school of business. At that point it was pretty separate, they wouldn't combine the two topics, but after that, I graduated. I did get my first job in a nursing staffing office and started to learn all about staffing and all the troubles with staffing and the issues and challenges.

Deborah:
From there, I ended up getting the same type of role, including payroll and could see how the two of those were complimenting each other. Sick calls, how much we were paying for sick calls, things like that. Then there was another person that also did patient acuity and that person left. Then I pulled in the patient acuity job and it was basically rounded out everything, looking at staffing, finance, budgeting, overtime, all those kinds of things, how they fit together.

Deborah:
I also had a director at that time, who was a director of nursing finance, and she was really a woman ahead of her time. She taught us everything she knew. She wanted to make sure... she always said, if she stepped off the curb and got hit by a bus, everything should function as if she was there. She was very generous with her learning and I just started finding it fascinating. As time went on, I became the Director of Nursing Finance under VP's of nursing.

Deborah:
Then about five years ago at NYP, New York Presbyterian, they developed this role that actually is a director of finance, and I am part of the finance department. I do have a dotted line to the CNE, the chief nurse executive for the enterprise. My role is to basically work with all the CNOs from the enterprise and help them with their budgeting, help them with their variance reporting, help them with their staffing, modeling, all those different things.

Deborah:
I've learned a lot going to the finance department, just a much broader point of view about healthcare financing and budgeting and financing and how it all fits together. Now more than ever it's really important for nurses to understand that.

Dan:
Yeah, it's definitely a gap that I hear a lot in the chief nursing suite is the finance side. What do you see as the biggest opportunity for nursing leaders to brush up on as it relates to finances? Is it budgeting? Is it projections? What do you see as that biggest gap?

Deborah:
The biggest gap is understanding budgeting terms, financial terms, and being able to speak to the finance people as peers and colleagues. Not to think of them as this other department that really is not concerned with patient care, which of course as nurses, that is our primary focus, but actually becoming friends with them. Actually looking at how they can help you and how you can help them.

Deborah:
I think one of the most difficult things we as nurses have, is to be able to articulate what we are doing, what our struggles are into terms that a financial person can understand.

Dan:
That makes sense and I know we've had conversation around... I think there's always this perception of the finance people are the barrier to any evidence-based practice or innovation or staffing or whatever the problem of the day is. What are the terms and the specific pieces that you see as a disconnect between when nursing describes a problem versus how finance describes a problem?

Deborah:
A lot of time as nurses, we have our own language. A nurse can talk with me and tell me about her day and how busy she was or he was, how crazy this was and that was and I will understand absolutely. One of the biggest things I had to get used to in finance, is people don't get that emotional about things.

Deborah:
Once we start throwing around a lot of adjectives and not speaking about specific data... Data and collecting data is one of the most important things that we can do as clinicians, to be able to prove our point or put forth a business plan that identifies why we need it. What were the purposes? How much do we need? Be able to have data to support all of that. I think we don't do a good job of collecting data.

Dan:
Yeah, so is that how you make friends with the finance department, is you come with data and leave the emotions at the door?

Deborah:
Yes. Yes. They do not get emotional. My finance VP is like, sometimes I'm all worked up about something and I could see his face like as I'm carrying on.

Dan:
Yeah. He's like, "Okay, just tell me, what's happening? We'll make a decision," right?

Deborah:
Exactly.

Dan:
One of the gaps I see as well as this projection of staffing and the ideas around full-time staff, travelers, contingent, sick time, overtime, like all of those complex pieces. How do you help nurse executives understand the complexities of the staffing world and actually create a forecast for solving that problem?

Deborah:
I think each organization handles it differently. There are reports that get generated. I think nurse leaders have to understand the reports. I mean, let's face it, the hospital is a business in the sense that it has expenses and it has revenue. Because most hospitals in the country are non-profit, hopefully the revenue is on par where the expenses are a bit more. I think understanding where the different units are in connection with their performance financially is an important thing.

Deborah:
The other thing is, understand what's behind the budgeting process. I've met CNOs who are not involved in the budgeting process at all, which is in my perspective terrible, because they are the people that have to tell us in finance what is going on and how to handle it. The other thing is like, how do they handle coverage factors, right? Is there a built-in coverage factor? Do you cover vacation? Do you cover sick time? Do you cover holidays, personal days? How does that differ from department to department? Because a 24 hour, seven day a week department needs to have people there round the clock. As whereas another department say a cath lab may only have people there Monday through Friday, maybe a smaller crew on Saturday, but those are the kinds of things. Is there enough backfill, I call it, but filled into the budget so that you're able to meet the staffing needs for a particular day?

Deborah:
Volume in each department is a key indicator and how that volume is in the budget, every department has a budgeted volume number. Inpatient is more like an average daily census and OR would be procedures. Cath lab would be cuts, you get the idea. That's really important to know where that is and to track it on a weekly or a monthly basis to see where you are in relationship to the budget. That will help you understand if you need more or if you're on par. We have swings in volume in all departments, so those are very important metrics to track.

Dan:
You have to understand that not only the patterns of your admissions or procedures, but also the patterns of behavior for your staff. Both of those are unpredictable to some degree and so you have to build in those variants levels or those buffers so that you're not scrambling for things last minute.

Deborah:
Exactly, and there are definitely seasonal patterns to people taking vacation. Of course, February, president's week, a lot of families go away, that's usually a big vacation time. Of course, the summer is a big vacation time, the first week of school once you get around Thanksgiving and the holidays. There are patterns and if they have a time and attendance system, they should be able to identify those patterns for each department that reports to them.

Dan:
Yeah, and what about the frontline clinical nurses, how can they contribute to the financial health of the organization?

Deborah:
I think now more than ever, it is crucial that the frontline nurses understand how their practice influences finance and what they can do to help reduce expense. One of the ways are med-surg supplies, do you carry around a pocket full of things just in case you need it? At the end of the shift, they have to be thrown out. An isolation room gets full of equipment that most of it has to get discarded.

Deborah:
Do you pick just the first thing you see in the utility room when you go in there, rather than, "Oh, that's not really what I need. I could get something a little bit," let's say gloves are an example of that, there's all different kinds of gloves. That's one way the frontline staff can really help, and any leader can talk to their frontline staff and get a ton of information on how supplies are wasted. We did a whole big initiative where we would talk with the frontline staff and got a dozen ideas, so many ideas about how we can decrease the waste of med-surg supplies.

Dan:
I think that's a key point there too. When I was in the ER as a frontline nurse, I remember our nurse manager came in one day and said, "We're having budget issues. If you guys could just use four pieces of gauze instead of seven pieces of gauze." I just remember looking around the room and myself included just rolling our eyes like, "Who the hell are you to tell us what gauze to use?"

Dan:
I like the way you approach it which is, talk to the frontline and say, '"What are your practices? What could we do better and how can we enable you to make better choices?" Because ultimately at the end of the day, they have to deliver the care and they're going to do it the way they do it.

Deborah:
Of course.

Dan:
Engaging them versus telling them to stop using gauze is a very different mentality I think.

Deborah:
Yeah, I could see that.

Dan:
It's that innovation like that top down stuff in that particular, I just remember my eyes rolled about 400 times. I think that the staff even started using more gauze just to spite that statement, so that's not the way to do it.

Deborah:
Right. I remember we went into one isolation room and took all the things out that were being thrown out and it was like $500-

Dan:
Wow!

Deborah:
... that had to be put in the trash, but what also, what we did was we put up signs. We worked with our purchasing department and we put up signs like [inaudible 00:10:42] with dollar signs. That $1 sign meant that was the least expensive item. One example was a single Foley catheter was very inexpensive, but if you grabbed a Foley catheter that had a bag, drainage bag with it and didn't need that, it was like $23 compared to $2.

Dan:
Yeah.

Deborah:
Just having that awareness, people would hopefully choose the right items then.

Dan:
I love that. I love that and I think it is a matter of not understanding the implications there. I think in nursing school you're not taught how much things cost or even to think about that when you're grabbing things. I think there is a information gap and I love that dollar sign piece. It's not saying you can't use that item. It just say have an extra piece of data to make a choice, it ends up helping the patients in the end.

Deborah:
Yes, absolutely and now with HCAHPS and value-based purchasing, nursing practice can make or break the financial reimbursement for hospitals.

Dan:
Yeah.

Deborah:
Any kind of...

Dan:
60% of the labor force as well, right?

Deborah:
Absolutely, and 25% of that is nursing salaries.

Dan:
Wow!

Deborah:
I mean, things like CAUTI, CLABSI, MRSA, all of those things have nursing indicators, patient experience scores. How is your discharge instructions? Did you have your pain managed? These are all ways that nurses in their practice can understand how they can improve reimbursement, because the reimbursement is based on scores that we get from the government payers. Now the other payers are all adopting the same way of reimbursing.

Deborah:
Practice more than ever can be related to reimbursement, which someday I hope to write an article about that, because we've always as nurses been in the room in board charge, right?

Dan:
Right.

Deborah:
We could actually be a revenue generating department I feel, to help offset some of the needs that we might have that cannot be paid for.

Dan:
That's a dream of mine too is that, we can actually quantify the value of nursing practice into not the room charge, but into specific revenue generation, cost, expenses, liabilities, all the things that go into the budget. Just like they do with the physician groups and so I'm excited. Yeah. If you need a place to publish that, you let me know I'll help you out.

Deborah:
Okay. I mean, why is it important to generate revenue? As I mentioned, we're a nonprofit so anytime we need to buy equipment, CAT scanners, computers, we have to generate the revenue to purchase those ideas, those different objects. Basically, the more we are able to generate by good nursing practice, less waste, the more money is available for nurses, equipment, increases, salaries, all things like that.

Dan:
Right. Yeah. It's a cycle that definitely is missed. Do you have a recommendation for nursing schools on how they might incorporate a better financial acumen into the programs?

Deborah:
I think that basically, they have to introduce the topic. I don't know how much of a impression it will make, but start introducing it as far as being a component of practice.

Dan:
Yeah.

Deborah:
Even when we have nurses being promoted to being a nurse manager, we call them PCDs, there is a lot, so much that they have to learn not just about running it. Running a unit, having staff report to them, having patients report to them, all the different requirements that I don't even talk to them about finance for at least three to four months. Then it's like a slower method to teach them what's the first thing they should start looking at and things like that, because it is not the priority, but it should down the line become one of your priorities.

Dan:
Yeah, and one of the things I've noticed in recent years from one of my mentors, Bern Melnyk at Ohio State, which is adding the cost can factor into your evidence-based practice reviews. Not just saying, "Here's the best evidence," but here's also what it costs or saves or generates as part of that whole equation in an effort to get by. Not only from the nurses, but also from the finance folks I think that's a good start, and then starting your nurse managers on a formal curriculum around it, I think there's a lot to be developed there.

Deborah:
I mean it can be. It's like a treasure hunt sometimes. You could tell I really like it.

Dan:
Yeah. No. It's awesome.

Deborah:
Yeah. I mean, sometimes you're looking, where did I spend that money? Or why did I spend that money? You look at all the different things that would cause that kind of spending or whatever. Or where can I find some money to offset that? It could be a treasure hunt literally.

Dan:
I love it. Well and thinking of it like that makes it more fun I think too for the people who aren't into the finance side of things.

Deborah:
Yeah.

Dan:
There's a lot of ways that you can make simple cuts without digging in like that. Like, well we need more money, let's cut salaries or cut staff. There's like this knee jerk reaction, but if you actually understand the budget, there's a lot of leverage you can pull to find patterns and reduce costs. Or find pockets of money that are being spent in ways that aren't optimal, and so it really is a treasure hunt.

Deborah:
Yeah. I mean, and also, as I mentioned earlier, volumes do fluctuate. If there are times when your volume is lower than it usually is, don't hire an overtime person. See if somebody wants to take a vacation day, because the benefit of that is that they won't need to take that vacation day when your volume is higher. There are ways like that, that you can manage day to day that would help you not have to spend the money when your volume is low.

Deborah:
I think we get into this pattern of, I have this many patients so I need this many. I always have five nurses on every day. Well, maybe your volume isn't requesting that. We're looking at those kinds of things right now post COVID because some of our volume has not come back as quickly as we would have expected it.

Dan:
Exactly, and it goes back to those patterns piece. If you see patterns and you don't have to bring five on, you can have four that day. Or you can encourage vacations on certain times of the year instead of others and maybe incent that. There's a lot of different places to flex around with it, and I think that's one of the key factors that people don't associate with finance initially which is, the flexibility you have once you understand it.

Deborah:
Exactly.

Dan:
It's not as black and white as people make it out I don't think.

Deborah:
It's not black and white at all especially the nursing piece. Like my finance colleagues, they're always like, "It's so complicated." I'm like, "Yes, it is complicated." I don't think they really fully appreciated how everything is a yes, but. It's like, we're trying to look at our EDs across nine hospitals while we have small community hospitals. Then we have two major academic medical centers, they're spread out in the five boroughs so nothing is the same even though you try to standardize.

Dan:
You live in the gray.

Deborah:
Exactly, which I don't like anyway.

Dan:
Yeah. I want to switch gears a little bit into the COVID-19 piece. I know New York Presbyterian was at the epicenter of all of it, and there's a lot of still lingering emotions and impacts and things related to that. Generally, how is New York doing? How is NYP and the nurses doing as New York's in a pretty good reduction in infections? What is the state of the world over there?

Deborah:
We did have quite a run for it in March and April. May it started, I think the end of April it hit its peak and really actually decreased rather quickly. It's taken a while for everyone to recuperate. I mean, from a perspective of the nurses, they were just on the front lines and it made me so proud to be a nurse truthfully.

Deborah:
I was involved with it in the sense that I handled all of the agency nurses and all the supplemental nurses and the nurses that came from other organizations to help us. The military came and we built a field hospital, and so my role in it with that way and centralizing, deploying staff, that staff to different sites when they needed it. Because it did shift from time to time between all of the different site, the locations. I mean, the nurses just persevered on.

Deborah:
We're encouraging everyone to take PTO now, because as I mentioned, our volumes have not quite come back to where they were. I mean, we shut down all of our ORs. We turned operating rooms into ICUs. I think at one point we had like 3,500 positive COVID patients between all of the sites.

Dan:
Wow!

Deborah:
It was tremendous and the majority of them were ICU patients, but the organization, we had enough PPE. We were putting out emails, asking people to just be conservative where they could be. The senior leadership was definitely one of the thrusts were to protect our workers. We had people deployed from the finance department. They would go over to the hospitals and unpack supplies. They really got their eyes open. We had so many fatalities that they were just transporting bodies.

Deborah:
I mean, helping deliver trays. They would do whatever they needed to do to get through, so God bless the clinical staff, but also other people who were so willing to put themselves in harm's way.

Dan:
Yeah. Do you think that really helped them understand the work better so that now they got enough learnings to where they can actually make better, more informed decisions because they did step up and do that amazing work?

Deborah:
You can almost see physically how it changed them.

Dan:
Wow!

Deborah:
Yeah. I mean, it was really amazing and people just volunteered weekends, nights. They went on the night shift to deliver supplies or unpack supplies, because we were getting so many supplies in to take care of the patients.

Deborah:
I think there's lingering effects. The hospital has tried very hard in having, like our behavioral health departments at each of the sites have Webexs to talk about people's feelings. Also, now, we're pretty much, I don't want to say quarantined, but New York City, we spend most of our time in our homes because there's nothing opened to distract you in the city. The park is open, the Central Park it didn't close, but all the museums are closed. Broadway is dark. I mean businesses that you don't even think of, my shoe repair person, he's got all these shoes from Broadway. He does all their like different shows, soles the shoes and fixes them, they're all still in his shop. There's this, a little bit of a sadness over, still arching over.

Dan:
Yeah, like a ghost town. Yeah.

Deborah:
Yeah. Really, I mean, people are moving out. Every single day you see moving vans.

Dan:
It's not as bad in San Francisco, but there's definitely a shift and people are leaving the epicenter of the city and going to the outskirts. Or going back home to other states because the energy of this city is not there anymore.

Deborah:
Right. Right.

Dan:
One of the things we found in a survey we did with about 1,500 nurses was that, they felt there weren't a lot of support mechanisms for their mental and physical wellness during COVID. It sounds like NYP has done some great things with the mental health practitioners onsite and coaching that. But have nurses been encouraged to use that? Or do you see them kind of shying away from it? What's the uptake there?

Dan:
What we found is, unless you push the nurse to use it, they weren't voluntarily partaking in those resources, so I just wonder what your perspective is.

Deborah:
I think on the large scale, we've had the same experience. They pick up their bootstraps and just move on.

Dan:
Yeah.

Deborah:
I feel like I've had some post-traumatic stress from it and I wasn't in the hospital, so I can't imagine how they... I remember speaking to my colleagues and them telling me stories about the hospital that I was just like, it would really just bring me to tears. I can't imagine, but I agree. I think nurses in general don't understand how things affect them on an emotional level. We should really try to understand how we can make it okay for them to seek out support in that way.

Dan:
Yeah. I think that's a big piece of it, is make it normal, make it part of the end of shift even. I think there's a lot of tactics that we could think about, where it just becomes normal to debrief some of these stressful situations and not just leave it up to the individual to opt-in.

Deborah:
Right. Right.

Dan:
What advice would you give to other organizations that are seeing spike? I know we're now into flu planning and there's worry about it, this COVID plus flu. Maybe there will be another spike in some states. What's the biggest piece of advice you could give them?

Deborah:
What we did was we developed a different model of care. With all those ICU patients, we needed other nurses to help us, so periop nurses would help the ICU nurses, step-down nurses. There was a lot of postpartum, I don't know where people were having babies, but they weren't having them at the New York Presbyterian. I'm like, "Where could they have them?"

Deborah:
Anyway, we started training those nurses to support the ICU nurses. We developed like a pyramid type of care model, which we're actually using. I'm doing a surg model when we get this podcast. I'll be working on my surg model for the organization. Using an ICU nurse at the top of the pyramid and then underneath that, are their med-surg nurses or step-down nurses where we currently have our nursing education department giving them a one day course? By no means they won't be an ICU nurse. However, how can they support the ICU nurse in a better way?

Deborah:
This triad would be the ICU nurse and then a step-down nurse or a med-surg nurse. Then they'd have a support person or somebody else to help them do the running, answering call bells, doing whatever to support that triad. Some of the hospitals it's easier, like in the big hospitals, simply because they have a lot more ICU beds and a lot more step-down beds. In the smaller hospitals it is a bit more of a challenge, but the cross training, I think so far we've cross trained over 500 nurses to upscale we're calling it, so that they could feel better.

Deborah:
They would help, but they felt like they could do more and didn't know how to do more. Now we have them doing lines or things like that, that would help in ICU and they would take more patients. This triad would have, rather than an ICU nurse having two patients, this triad would have three to four patients, ICU patients, depending upon who is helping them.

Dan:
That's a really cool model and one of those innovations I'd love to push as well as this idea of breaking down the service line mentality and focusing more on competency and skill. I think that triad model is one way to do that, to bring the right skills to the patients when they need them, and be able to flex across the organization to meet the organization needs so I love that. I hope you write that up and get that out into literature.

Deborah:
Also, one of the things is, we have psychiatric behavioral health units in most of the hospitals. We consolidated them into two behavioral health hospitals, so we closed those units in the acute care hospital and filled them with patients and sent the behavioral health to other hospitals. We also did the same thing with pediatrics. We have a pediatric hospital, so pediatric census was low. We transferred our pediatric patients to that site so that their units in that acute care hospital could have adult patients.

Dan:
It's that flexibility is key?

Deborah:
Yeah, definitely and everybody was so willing to do whatever they could do to help. It was a beautiful example of partnership and collaboration.

Dan:
Yeah. I think that's the bright silver lining there is, crisis can bring people together and change the way we view things, change the way we think and hopefully change our organizations for the better moving forward. I think the worst thing we could do is to go backwards. I sound like a broken record because I feel like I say that every time, but we have to evolve from this.

Deborah:
Yes, absolutely.

Dan:
One of the things we like to do here is hand off that nugget of information to the listeners. That one piece that you think they should take away and execute in their daily lives tomorrow. What would you like to hand off to our listeners?

Deborah:
Since it was about finance our podcast, I would like them in some way to find out one piece of information about their practice. Or if it's not a clinical nurse, but the leaders to find out one thing about finance that you didn't know before. Or write an email to somebody in the finance department if you are a nurse leader and just say, "I'd like to learn more."

Deborah:
People write to me all the time, of course I'm a nurse, so maybe they're not as intimidated, but you'll find it interesting and I think it broadens your perspective. I think one of the things we do as nurses is have tunnel vision about nursing and patient care. We work in a huge complex industry and I think learning something new about our industry is really important.

Dan:
That's a great piece of advice. Jump in, make friends with your finance colleagues. They're not scary. They're nice. They like the same things you do. They're people too.

Deborah:
Exactly.

Dan:
They're not robots with spreadsheets.

Deborah:
They also want to feel... These individuals from finance who went to the hospitals, they want to contribute. They want to understand it, it's just such a mystery to them.

Dan:
Yeah.

Deborah:
I did write an article called demystifying the language of finance and they want to know. If we can speak to them, as I mentioned, not all riled up and not all in adjectives, but in real language, they appreciate it. They really do appreciate it.

Dan:
Great note to end on. Deborah, where can we find you? Are you on LinkedIn? If someone wanted to reach out and learn more about your finance work and just connect with you, where could they get that?

Deborah:
I am on LinkedIn. I'm always happy to support nurses in understanding because we're so smart. If we can figure out how to keep somebody alive, we can figure out nuts and bolts of finance.

Dan:
You can work an Excel sheet if you can work a pump, right?

Deborah:
Yes. Exactly.

Dan:
Well, Deborah, thank you so much for being on the show. I really appreciate it. I learned a ton about finance and thank you so much for all the work you did during COVID and supporting the nurses there as well. We look forward to learning more and diving into finance in the future.

Deborah:
Great. Happy to do it.