Episode 74: How UCLA’s Chief Nurse Executive maintains a high-performing culture
Episode 74: How UCLA’s Chief Nurse Executive maintains a high-performing culture
Listen on your favorite appEpisode 74: How UCLA’s Chief Nurse Executive maintains a high-performing culture
Dan:
Karen, welcome to the show.
Karen:
Thanks Dan. Great to be here. Thank you.
Dan:
So, you work for one of the most prestigious academic medical centers on the planet, and I might be a little biased there. And medical center is a different beast, I think, it has a lot of moving parts. It's associated with education. It's got residents, it's got nursing students, it's got all these other things that community hospitals don't necessarily have, which requires a special strategy as well. So as we move out of the pandemic, or into the endemic, what are some of the top of mind strategies to lead your center through the next few years?
Karen:
Thanks for asking that question. I think the most important thing, and I think it's one of the things that makes UCLA strong as an academic medical center, is our focus on relationships, and the care, tending and respect that it takes to build those relationships. And I think the pandemic really tested our medal, if you will, because maintaining those collegial relationships during a time of high stress and crisis can be really challenging, because that's usually when you find out things aren't going so well. And I think one of the neatest things for us here is that people manage those relationships and they continue to promote and invest in those relationships. And I think it made us stronger.
Karen:
So the goal now is to continue them and also to take advantage of the new relationships that were established. While we're a teaching hospital and a teaching system, and we have our residents and our fellows and our nurses and faculty at the bedside all the time, I think that COVID made that stronger. I think that each of the roles got to know each other differently, and possibly on a more intimate level when we think about what some of the challenges were around COVID. So maintaining those as we reset ourselves is only going to make us stronger. So relationships, relationships, relationships.
Dan:
Yeah. I love that. And one of my fanboy loves is Tim Porter O'Grady. And one of his quotes is, "Leadership is 90% relationships." And I think that's where you share that trusted information, and on the clinical team have trust in each other to do the right thing, and in a crisis when all the rules and stuff fly out the window to have that trust and be able to know that your partner in crime next to you has the right thing in mind and is looking out for you and you're looking out for them, I think that's the key and crisis catalyzes that.
Dan:
What were some of the innovations that happened? I know I've talked to some of your colleagues, Colleen and David and others that are UCLA, and they really talked about this idea of rethinking teaming, the fact that you had to bring in new nursing students, or contingent travel nurses and all these people moving in and out of the system and really focusing on how do you rapidly team in an environment where you may not be with the people that you're normally with. And what were some of the other innovations that happened during the crisis?
Karen:
I think one of the first things that we learned, it was this mad rush to make sure everybody had enough PPE. And I think one of the things we learned is that the PPE is only as good as the people who use it, as far as protective wear. And so, one of the things that became very important was the teaming around the use of the PPE, which also led to innovation because a lot of the face masks and some of the other things, and by that, I mean the shields, were very uncomfortable. And nurses were developing pressure injuries from some of the different items we had. And we ended up teaming with medical students and with residents and people in the engineering school. And this group actually was able to make a 3D printer version of a frame for a nurse shield that was much more comfortable and light to wear, that they were actually able to incorporate into practice.
Karen:
And so I think that, that expertise at the bedside, coupled with those young, and when I say young, I mean youthful, they don't have any barriers or boundaries, they're just thinking about neat and cool ways to do things. I think that blended with nursing's ability to fix and innovate anything real time blended to make some really interesting products. That was probably one of my favorites. Some of the other things that became really important and probably less sexy, or the relationships that were birthed from caring for the COVID patients, we created a quality monitor person who initially was there to make sure you donned and doffed your equipment properly, but quickly they became more of a emotional coach for a lot of our team. And they actually would begin to talk through some of the different things that people were thinking about, or some of the different fears that people had.
Karen:
And it was great because it started to blend what we were doing as far as bedside care into the, are we taking care of the nurse? So I think that was some of the stuff that really got us started on wellness and recognition. And our goal, of course now is to continue that level of recognition to the best of our ability, because it is so needed now that people are tired and trying to recharge their batteries, but the pace hasn't slowed down, we've just changed the patients. They're no longer COVID patients, they're people catching up with care. So there's been no downtime.
Dan:
Yeah. I think those are two great examples. One is leveraging the network that academic medical centers have, which is these other schools that are attached to them, whether it's a health profession school, or an engineering school, or a art school, all of those bright minds, cutting edge research, faculty, students all have this desire to create as they go through programs and things and the leverage that is awesome. I love that story of the face mask and using the frontline expertise coupled with the ingenuity and the technology, creating something that actually is functional in the moment. And I keep thinking, how can we replicate that every day? Why does it have to take COVID or a crisis to accelerate things like that when we can make that the operating system that we use all the time.
Dan:
And then the other piece of the emotional coach is great too. You have this idea of this role, but we have to adapt and evolve very quickly as we get new information. And we see these things happening. And to adapt from donning and doffing compliance role to, hey, let's debrief and have this emotional connection with people, I think what a wonderful way to evolve a role over time. And I think those are two things that our listeners can take away is, innovation happens in the moment. It doesn't have to be this huge funded, multiple approvals through a million board people. It really can be in the moment shifts that allow for impact for the people providing care.
Karen:
And Dan, that gets back to Tim Porter O'Grady, probably one of the first nursing thought leaders I met, which was a really long time ago, and I won't tell you the year, you may not have been born. But anyway, it's that whole thing, it's about shared governance. It's about professional governance, because what you're describing is that ability to influence and impact your practice by using your unit based practice council or your other councils, we were able to keep our councils functioning for the most part, we did have a hiatus and we let the councils decide when they would have a repeat hiatus as we got into our second and third surges. I think that helped us a lot. I think it helped us stay focused on practice and it also helped us stay in tune across all of nursing with one another.
Karen:
I think when we made the decision to make for ICU our COVID unit, for intensive care patients, we had two other units that volunteered to go down and cross train to relieve them, which well, I guess nurses run in, nurses and firefighters. We run in when the place is burning. But to think that your colleagues in another area of the hospital felt your pain or understood your need and showed up was so invigorating for all of our nursing staff. It just tells a lot about who UCLA nursing, or nurses are and their compassion and their need to be connected in their caring for all patients and each other.
Dan:
That's what I remember about UCLA. Now, it was 2005, I started as a new grad in the basement of UCLA, but I just remember the culture was so intense in a good way. I remember walking in, and the expectation was you got better every day. And if you weren't getting better, then there were conversations. Good conversations were had about how do we help you? But there was an expectation that you would get certified, and that you would help each other. And that we all had to be at this high performing team level because there's no other option at UCLA.
Dan:
And so, I think it really does speak to that idea of we're in this together and at UCLA experts in this work. And so there's almost no other option than to do what you described. It's just part of what that culture is. How do you maintain that culture? What do you think are some of the drivers that keep that high performance team supporting each other culture within the organization?
Karen:
I think the thing is, is we have CICARE care. It started is an acronym many years ago, but it's essentially about connecting with the people you work with and connecting with the patients you care for, in such a way that it's birthed out of respect, it's birthed out of acknowledgement. And part of the respect is not just for you as a human, but for your expertise as well. And I think we carry that with us.
Karen:
So CICARE has turned into a cultural imperative for us, and it's far greater than words like connect, introduce, et cetera. I think that's really set us apart. And I think the other pieces too is it's also taught us to look for the individual patient through the myriad of pumps and tubings and machines. We see people and then we see the machines. And when you talk to our patients, especially those that were in the intensive care units, they'll tell you that. They always felt like a person. And I think that, that mindset and the pride we take in what we do probably makes this a self-fulfilling prophecy. We know we have to do the best because people need the best. And to do that, we have to be the best. And for me, my job and the job of the leaders here is to move barriers and to provide the resources necessary for the best to continue to deliver the best.
Dan:
It definitely is a special place to learn and work. And I think that, that's just an amazing piece of it. And I want to go back to another thing you mentioned, which was the shared governance work. We were both actually at American Organization of Nurse Leaders Conference a couple weeks ago in San Antonio. And one of the themes that a lot of nurse leaders I talked to had was they shut down their shared governance work almost completely like it just left the building. I think Tim Porter O'Grady's actual end note on Tuesday was where did it go? It was here. And then all of a sudden when things get tarred, we've got to get rid of it. And you were able to maintain it in some capacity.
Dan:
So what are some tips for nurse leaders to think about as the next thing happens and things get tough, it's the running joke is education and sure governance goes out the window whenever the times get tough. But how did you maintain that? Or what are some tips for leaders to think about as they rethink about, how do they maintain some of these core pieces that advance our practice and keep our practice safe in times of crisis?
Karen:
I think you just said it core shared governance or professional governance has to be a core practice. And if it's a core practice, you're going to keep it. If it's not so core, why not? And what is it that I need to do as a leader to make sure that it stays top of mind? What are the things that I need to instill in the people at the C-suite level, at the board level, that help people understand what we get as an organization and what our patients get, because we have such a strong professional practice. And we do it here by translating it in the form of our magnet accomplishments, but then also what we help push as far as clinical outcomes, engagement, patient experience, even throughout COVID we maintained our patient experience scores with [Preski 00:14:09], it's because it's who we are.
Karen:
So I guess the thing is, is if, if professional governance or education, or different things that you offer people all the time are just a new layer and you haven't incorporated it into your culture, you will discard it when things get tough. I guess my challenge to all the nursing and health system leaders is what is the value that you place on nursing? And what is your understanding of the role that professional governance and education play in that? And if you value it, it won't go away.
Dan:
Yeah. I think that's a great message is, if it's core, if it's a part of the culture, it doesn't just disappear. If it's a thing you do, it can disappear quite quickly. But if it is that core piece of your value set, that's not going to change and people will rely on it as a way to move forward and to find some stability in the chaos as well, which I think is another great piece of what professional governance allows for, is to consult each other and share that information to make more informed decisions and not just lock into silos of ICUs and EDs and all that stuff that we can easily do and actually share information to move forward. So, that's really exciting to hear. And I think the listeners need to take away that shared governance is a piece of the culture, it's not a thing you do. And to treat it that way.
Karen:
Well, one of the things for me too, being at UCLA, we have a lot of resources. So it's probably easier for me to reinforce all of this. I can think that people in a critical access hospital, or people in a smaller community hospital, this would be extremely challenging, because we have staff who come in to work on committees and who... You know what I mean? We fund that. So when you come in to work on your professional practice council, we underwrite that, it's not volunteer time. It's part of who you are as a nurse and our organization, the role that you have on that committee. So it's compensated. That can be a big ticket for a small organization.
Dan:
Yeah. But I think what you also mentioned is the returns are worth it as well. So, you see these changes and adaptations in real-time with that sort of work. So the investment isn't just about dollars, it's about also this return of better practice and a culture that can navigate through even the toughest time. So it is that balance, but that's also a good point, you have to resource it as well.
Karen:
Yeah. But I think the other piece that you just brought up too, is the value prop. So that nursing officer who says, I need to do this, and this is what I need to make it happen, she or he has to be willing to say, and this is going to improve our CLABSI rates. This is going to reduce our falls. This is going to improve our patient experience. And put your money where your mouth is. Own that metric, that you know will be impacted by your investment.
Dan:
Yeah. I think that's a great point. Going along those lines of resourcing, one of the things I've heard over and over is, well, we didn't have the staff to actually do this. And so I know one of the things that you're passionate about is this future of staffing strategy. And one of the things I've been saying is, and it's a provocation, but it's also true. You'll never, ever, ever be fully staffed ever again. And so you have to think about staffing differently. And that doesn't mean you won't have enough people to do the work, you just won't have the same full-time employees to do it. And you may have to have flexible float pools or external labor, new roles, or those type of things. So we have to think about staffing, not like we did pre-pandemic where you just throw nurses at the problem, but to really think about this different way of work as the entire country and every industry is rethinking what work means. And so would love to hear your thoughts on how you're thinking about strategy around staffing.
Karen:
To your point, we have to understand what is it we need. And the second piece is nurse scheduling since the Baylor plan and the shift to 12 hour shifts, which has been a very long time now. We've gotten really rigid, at least in the inpatient side, to the point where, I've been in environments where people will say, oh no, people can't work part-time and to have 12 hour shifts, they have to work three shifts. And it's like, that makes no sense. You know what I mean? So it's like, wouldn't you rather have somebody who can give you two twelves a week and know that they're going to come in and they love their job? And that pre-pandemic was even a hard sell. Today what I think we have to do is I think we have to look back on history. I had a nursing history professor who taught me there has always been a nursing shortage.
Karen:
And I think time spent in Florida for me as a CNO, Florida on the coast with snowbird deals with nursing shortages every season. So you learn some ways to become very resilient and self-sufficient. And so I think that taking some of those things I learned early in my career and looking at what we've realized with the pandemic, I think as leaders, we have to challenge ourselves to let go. I think we have to understand that we're always going to have some level of vacancy, and how do we mobilize for that? So for us here, for example, we took the time to recalibrate our positions. And in doing that, we identified that because of leaves, increased absenteeism and all sorts of other changes, vacancy rates, turnover, et cetera, we had what we would call an operational vacancy that was much higher than the actual vacancy that you would find in human resources in their statistics.
Karen:
So what we did was we crafted a strategy with finance and we put those positions on each of the individual units rosters so that they can essentially overhire to accommodate orientation, turnover, absenteeism, prolonged leaves, et cetera. We've been doing that since July with good effect. And so while it's always challenging for a financial office to say, okay, I get this, yeah, this makes sense. For us it's allowed us to keep the pipeline greased. That's a strategy that we put in place last year and we plan to keep ongoing so that we are always able to interview the best and the brightest. So in keeping with that, we've also looked at how do we partner differently with local schools, whether it's schools for nursing assistants, scrub techs, RNs, it doesn't matter. How do we partner with them differently to almost create an apprenticeship while they're still in school and they make their transition over to an acute care environment like UCLA, or any other hospital for that matter?
Karen:
How do we start to formulate relationships and modify things that we've always done that way so that they help us lay in a way to get to the level of experts we need in our organization to care for our patients, regardless of the role? So, those partnerships are really important. Other things that we've done is, what do you do for a float pool? Do you have your own float pool, or do you rely on travelers and other third parties to help supplement your staffing? We've had a commitment since I've been here to build a float pool that can support our regular absences, as well as backfill a percentage of our leaves. This absolutely helped us when it came time for COVID because we weren't as reliant on third party agencies to find nurses.
Karen:
So our traveler numbers while they popped up a little bit were well below what probably many of our other facilities in our area and nationally were running. So it's how do you become more self-reliant? And how do you start to anticipate needs? Other things that we've hardwired as well is we've got a slew of nurses who are in the tail end of their career. And you know what? 12 hour shifts in our environment are exhausting. And they've had comments like, if I could just do eights, or if I could just do sixes, I could do this and I won't need to retire. So we've created break shifts and other shifts of time in the course of a 24 hour day where people can pick up six or eight hours, and contribute to their unit in a very meaningful way by taking patient care so that other people can have breaks, or do whatever they need to do, or to take on admissions while the rest of the nurses are caring for their patient population. So everybody's satisfied, and we still have nurses with experience.
Karen:
We stand to lose a lot of institutional knowledge here because a fair number of people put off retiring when the economy got a little soft a few years ago, coming out of COVID people who had planned to retire in the past, and now at a point where they'd like to retire, and then we have the great resignation built on the people who have just tired, or don't want to practice anymore. So it's a balancing act, I guess.
Dan:
I would say a lot of the flux within the day to day operations are what you mentioned, planned leaves or a trended absentee based on sick calls or whatever it is. And so that float pool makes a lot of sense and then supplementing these unexpected pieces with more flexible work and different levels of FT, it doesn't have to just be a 0.5, a 0.8 and a 0.1, you can do other things and to be open to those things. And I think, one of the other pieces that I really think helps UCLA as well is that you have such a great new graduate program as well. And you allow new graduates to start in almost any specialty area that exists there. I started as in the ER, I know I interviewed at the CT ICU, and I just remember how amazing that was when all my faculty and all my other cohort of students are like, well, we're going into med-surg. And I was like, that wasn't my passion. If I would've gone to med-surg, I would've quit nursing after year one probably, just because it just wasn't who I am.
Dan:
I'm an ER nurse all the way through. I figured that out and that's still in my blood, but I think allowing for people to have that passion and find it early on in their career allows for them to also stay with the organization longer, because they don't have to pay their dues necessarily in that way. That's also a talent strategy that other systems need to start adopting too.
Karen:
And I think paying your dues, it's like eating your young. Why? If somebody has a skill set and the interest and they're trainable, why can't they start anywhere? And med-surg has become its own specialty now. So to think that having somebody work med-surg is going to teach them anything about a particular intensive care unit, or some other location in the hospital, might be foolhardy. You know what I mean? We might just be living off an old tradition, which is dangerous. And then we need to really pay attention to what we let go of, because sometimes we let go of things way too soon. And one of the things that always comes to mind for me, because I was one of them, was the three to 11 shift. I couldn't think of a better shift to work in an emergency room, Dan, than that when I was doing my clinical time. And we eradicated that. And I think we didn't study it enough before we had it go away and we lost a lot.
Dan:
Yeah.
Karen:
And one of the biggest, funny story having worked three to 11, we always used to give PM care. We'd tuck everybody in, brush their teeth, face, back rub, all that kind of stuff. I remember my first CNO job, I went upstairs to help on a unit and I said, I can at least help everybody get set up for bed. And they looked at me and they said, what are you talking about? And I went, don't you tuck everybody in? No, we lost it. The [Kanban 00:26:18] was so important. We lost it. I don't know that we've ever gotten it back consistently.
Dan:
Yeah. Three to 11, that's the busiest time. Why not up staff or have people that love that? I was night shift for a long time, and right around 2:00 AM you're bored, there's not a lot going on and so, but you felt, oh, just craziness up until then. So how do you staff up on some of those surges and things and just, yeah, again, we have to question, what did we get rid of and what are we not doing and where were some of these innovations working in the past and can we go back to them too? And I think that what's old is new sometimes, and we get rid of things and I think exploring those are really good. So the last topic I wanted to chat with you on is your work with Vizient. I know you're doing some great stuff related to healing and supporting the profession. So I'd love to hear more about what you're up to with Vizient.
Karen:
Well, we all know that as the nursing shortage approaches, or I would say we're waiting in pretty deep right now, we have national benchmarks that a lot of us use every day. And the tough part is, is a nursing shortage when you start to look at productive hours per patient day on an inpatient unit, if you have a nursing shortage and are unable to staff, that's going to drive down your hours per patient day that you're actually being able to provide. And in turn that could actually drive productivity benchmarks across nursing down in a not so good way, because they wouldn't really be reflecting what a healthy cohort of hospitals are doing with their patient populations based on acuity. It suddenly becomes a tumble as the staffing falls away. So one of the pieces that's really important for me is to get the word out, to remind people to watch their hours for patient day and understand the impact that the shortage may be having on them.
Karen:
And in turn, start those conversations with finance officers and with C-suite members and even your colleagues to say, you know what? I anticipate this is going to drop a little bit because we're not able to staff, but for me to maintain adequate staffing, I need to maintain my hours per patient day, where it is now, not where it may tumble to. So please know that I will continue to recruit. I will continue to do my best to maintain the staffing ratios and things like that, or the staffing requirements for my patients, despite what the benchmarks are telling you.
Karen:
And I think we all know that as people yet to C-suite levels and other levels, they're handed reports on a monthly basis or weekly basis depending, and those are some of the things they watch all the time, because labor is, of course, the largest expense in any health system. And so the first group that always gets looked at is nursing because we're the largest group. So helping prep our finance officers and our other members of the team at that level, that while this is anticipated, it is not something to hang our hats on, we need to go back and look at numbers from 2019 and think benchmarks from 2019, or before, so that we don't make a fatal error in our staffing and essentially prolong the nursing shortage, because we would create its continuance by accident, by responding or reacting to the numbers.
Dan:
Yeah, I think that's a good lesson to have around the benchmarking piece. And I think a lot of people try and achieve the benchmark, but that's just achieving what others are doing. And so if you have an idea of innovation, you want to exceed those benchmarks, or blow up those benchmarks, or create new metrics that show different things. And I think that's a key to being nimble and adapting and not just trying to be like others, because there's definitely nuances in all of that stuff like you mentioned, and the benchmarks are one data point, not the data point. And so I think rethinking those pieces is a key leadership tactic.
Karen:
Right. And the thing that nurse leaders need to remember is we are the experts in that, not finance, no one else. We need to understand what we need to get the job done. And then we need to keep people cognizant of that so that we continue to provide the level of care needed for our patients.
Dan:
Well, Karen, this was awesome. I really appreciate your time today and chatting through all of those things that are just so important for us to lead out of the pandemic, the innovation, and just the amazing culture that UCLA is, that is in part because of your team's leadership. And so, one of the things we like to do at the end of the show is provide a handoff, that one piece of information, or that one nugget that you want to share with the world that they may take away and implement tomorrow. So what would you like to hand off to our guests?
Karen:
I think, especially for leaders, being present, and for all of us, being present, because I think it gives us the opportunity to actively listen and put yourself in places where it's important to listen, rounding meetings with colleagues, meeting with staff, so that you can be your authentic self. You can listen, understand and take what you're hearing back and use it to help provide better leadership. There's nothing like listening to your staff.
Dan:
Yeah. If people want to reach out or learn more about your work, where's the best place to find you?
Karen:
Oh, UCLA, KGrimley@mednet.ucla.edu.
Dan:
And LinkedIn, I know you're on LinkedIn every once in a while as well. And so check out UCLA, especially for those new nurses looking for roles, experienced nurses, UCLA is just an amazing place. And I was only there for a year, but I credit that year as probably one of the most catalyzing experiences for my entire work. And so I just have so much respect for you and your leadership and the organization as a whole. And just really appreciate your time on the show today.
Karen:
Thank you. It's my pleasure, Dan.
Dan:
Thank you so much for tuning in to today's episode of The Handoff. If you liked what you heard, please consider leaving us a review on Apple Podcast or wherever you listen to podcasts. You can also subscribe and receive new episodes at www.thehandoffpodcast.com.
Description
Our guest for this episode is Karen Grimley, Chief Nurse Executive at UCLA Health and Assistant Dean for the UCLA School of Nursing.
In this interview, Karen and Dan talk about the innovations that the UCLA staff developed during COVID, how Karen maintains a high-performing culture and how she’s planning to lead coming out of the pandemic. Karen also shares how she’s thinking about staffing and scheduling and the concept of flexible work at UCLA, how you can maintain best practices around shared governance in a time of crisis.
Transcript
Dan:
Karen, welcome to the show.
Karen:
Thanks Dan. Great to be here. Thank you.
Dan:
So, you work for one of the most prestigious academic medical centers on the planet, and I might be a little biased there. And medical center is a different beast, I think, it has a lot of moving parts. It's associated with education. It's got residents, it's got nursing students, it's got all these other things that community hospitals don't necessarily have, which requires a special strategy as well. So as we move out of the pandemic, or into the endemic, what are some of the top of mind strategies to lead your center through the next few years?
Karen:
Thanks for asking that question. I think the most important thing, and I think it's one of the things that makes UCLA strong as an academic medical center, is our focus on relationships, and the care, tending and respect that it takes to build those relationships. And I think the pandemic really tested our medal, if you will, because maintaining those collegial relationships during a time of high stress and crisis can be really challenging, because that's usually when you find out things aren't going so well. And I think one of the neatest things for us here is that people manage those relationships and they continue to promote and invest in those relationships. And I think it made us stronger.
Karen:
So the goal now is to continue them and also to take advantage of the new relationships that were established. While we're a teaching hospital and a teaching system, and we have our residents and our fellows and our nurses and faculty at the bedside all the time, I think that COVID made that stronger. I think that each of the roles got to know each other differently, and possibly on a more intimate level when we think about what some of the challenges were around COVID. So maintaining those as we reset ourselves is only going to make us stronger. So relationships, relationships, relationships.
Dan:
Yeah. I love that. And one of my fanboy loves is Tim Porter O'Grady. And one of his quotes is, "Leadership is 90% relationships." And I think that's where you share that trusted information, and on the clinical team have trust in each other to do the right thing, and in a crisis when all the rules and stuff fly out the window to have that trust and be able to know that your partner in crime next to you has the right thing in mind and is looking out for you and you're looking out for them, I think that's the key and crisis catalyzes that.
Dan:
What were some of the innovations that happened? I know I've talked to some of your colleagues, Colleen and David and others that are UCLA, and they really talked about this idea of rethinking teaming, the fact that you had to bring in new nursing students, or contingent travel nurses and all these people moving in and out of the system and really focusing on how do you rapidly team in an environment where you may not be with the people that you're normally with. And what were some of the other innovations that happened during the crisis?
Karen:
I think one of the first things that we learned, it was this mad rush to make sure everybody had enough PPE. And I think one of the things we learned is that the PPE is only as good as the people who use it, as far as protective wear. And so, one of the things that became very important was the teaming around the use of the PPE, which also led to innovation because a lot of the face masks and some of the other things, and by that, I mean the shields, were very uncomfortable. And nurses were developing pressure injuries from some of the different items we had. And we ended up teaming with medical students and with residents and people in the engineering school. And this group actually was able to make a 3D printer version of a frame for a nurse shield that was much more comfortable and light to wear, that they were actually able to incorporate into practice.
Karen:
And so I think that, that expertise at the bedside, coupled with those young, and when I say young, I mean youthful, they don't have any barriers or boundaries, they're just thinking about neat and cool ways to do things. I think that blended with nursing's ability to fix and innovate anything real time blended to make some really interesting products. That was probably one of my favorites. Some of the other things that became really important and probably less sexy, or the relationships that were birthed from caring for the COVID patients, we created a quality monitor person who initially was there to make sure you donned and doffed your equipment properly, but quickly they became more of a emotional coach for a lot of our team. And they actually would begin to talk through some of the different things that people were thinking about, or some of the different fears that people had.
Karen:
And it was great because it started to blend what we were doing as far as bedside care into the, are we taking care of the nurse? So I think that was some of the stuff that really got us started on wellness and recognition. And our goal, of course now is to continue that level of recognition to the best of our ability, because it is so needed now that people are tired and trying to recharge their batteries, but the pace hasn't slowed down, we've just changed the patients. They're no longer COVID patients, they're people catching up with care. So there's been no downtime.
Dan:
Yeah. I think those are two great examples. One is leveraging the network that academic medical centers have, which is these other schools that are attached to them, whether it's a health profession school, or an engineering school, or a art school, all of those bright minds, cutting edge research, faculty, students all have this desire to create as they go through programs and things and the leverage that is awesome. I love that story of the face mask and using the frontline expertise coupled with the ingenuity and the technology, creating something that actually is functional in the moment. And I keep thinking, how can we replicate that every day? Why does it have to take COVID or a crisis to accelerate things like that when we can make that the operating system that we use all the time.
Dan:
And then the other piece of the emotional coach is great too. You have this idea of this role, but we have to adapt and evolve very quickly as we get new information. And we see these things happening. And to adapt from donning and doffing compliance role to, hey, let's debrief and have this emotional connection with people, I think what a wonderful way to evolve a role over time. And I think those are two things that our listeners can take away is, innovation happens in the moment. It doesn't have to be this huge funded, multiple approvals through a million board people. It really can be in the moment shifts that allow for impact for the people providing care.
Karen:
And Dan, that gets back to Tim Porter O'Grady, probably one of the first nursing thought leaders I met, which was a really long time ago, and I won't tell you the year, you may not have been born. But anyway, it's that whole thing, it's about shared governance. It's about professional governance, because what you're describing is that ability to influence and impact your practice by using your unit based practice council or your other councils, we were able to keep our councils functioning for the most part, we did have a hiatus and we let the councils decide when they would have a repeat hiatus as we got into our second and third surges. I think that helped us a lot. I think it helped us stay focused on practice and it also helped us stay in tune across all of nursing with one another.
Karen:
I think when we made the decision to make for ICU our COVID unit, for intensive care patients, we had two other units that volunteered to go down and cross train to relieve them, which well, I guess nurses run in, nurses and firefighters. We run in when the place is burning. But to think that your colleagues in another area of the hospital felt your pain or understood your need and showed up was so invigorating for all of our nursing staff. It just tells a lot about who UCLA nursing, or nurses are and their compassion and their need to be connected in their caring for all patients and each other.
Dan:
That's what I remember about UCLA. Now, it was 2005, I started as a new grad in the basement of UCLA, but I just remember the culture was so intense in a good way. I remember walking in, and the expectation was you got better every day. And if you weren't getting better, then there were conversations. Good conversations were had about how do we help you? But there was an expectation that you would get certified, and that you would help each other. And that we all had to be at this high performing team level because there's no other option at UCLA.
Dan:
And so, I think it really does speak to that idea of we're in this together and at UCLA experts in this work. And so there's almost no other option than to do what you described. It's just part of what that culture is. How do you maintain that culture? What do you think are some of the drivers that keep that high performance team supporting each other culture within the organization?
Karen:
I think the thing is, is we have CICARE care. It started is an acronym many years ago, but it's essentially about connecting with the people you work with and connecting with the patients you care for, in such a way that it's birthed out of respect, it's birthed out of acknowledgement. And part of the respect is not just for you as a human, but for your expertise as well. And I think we carry that with us.
Karen:
So CICARE has turned into a cultural imperative for us, and it's far greater than words like connect, introduce, et cetera. I think that's really set us apart. And I think the other pieces too is it's also taught us to look for the individual patient through the myriad of pumps and tubings and machines. We see people and then we see the machines. And when you talk to our patients, especially those that were in the intensive care units, they'll tell you that. They always felt like a person. And I think that, that mindset and the pride we take in what we do probably makes this a self-fulfilling prophecy. We know we have to do the best because people need the best. And to do that, we have to be the best. And for me, my job and the job of the leaders here is to move barriers and to provide the resources necessary for the best to continue to deliver the best.
Dan:
It definitely is a special place to learn and work. And I think that, that's just an amazing piece of it. And I want to go back to another thing you mentioned, which was the shared governance work. We were both actually at American Organization of Nurse Leaders Conference a couple weeks ago in San Antonio. And one of the themes that a lot of nurse leaders I talked to had was they shut down their shared governance work almost completely like it just left the building. I think Tim Porter O'Grady's actual end note on Tuesday was where did it go? It was here. And then all of a sudden when things get tarred, we've got to get rid of it. And you were able to maintain it in some capacity.
Dan:
So what are some tips for nurse leaders to think about as the next thing happens and things get tough, it's the running joke is education and sure governance goes out the window whenever the times get tough. But how did you maintain that? Or what are some tips for leaders to think about as they rethink about, how do they maintain some of these core pieces that advance our practice and keep our practice safe in times of crisis?
Karen:
I think you just said it core shared governance or professional governance has to be a core practice. And if it's a core practice, you're going to keep it. If it's not so core, why not? And what is it that I need to do as a leader to make sure that it stays top of mind? What are the things that I need to instill in the people at the C-suite level, at the board level, that help people understand what we get as an organization and what our patients get, because we have such a strong professional practice. And we do it here by translating it in the form of our magnet accomplishments, but then also what we help push as far as clinical outcomes, engagement, patient experience, even throughout COVID we maintained our patient experience scores with [Preski 00:14:09], it's because it's who we are.
Karen:
So I guess the thing is, is if, if professional governance or education, or different things that you offer people all the time are just a new layer and you haven't incorporated it into your culture, you will discard it when things get tough. I guess my challenge to all the nursing and health system leaders is what is the value that you place on nursing? And what is your understanding of the role that professional governance and education play in that? And if you value it, it won't go away.
Dan:
Yeah. I think that's a great message is, if it's core, if it's a part of the culture, it doesn't just disappear. If it's a thing you do, it can disappear quite quickly. But if it is that core piece of your value set, that's not going to change and people will rely on it as a way to move forward and to find some stability in the chaos as well, which I think is another great piece of what professional governance allows for, is to consult each other and share that information to make more informed decisions and not just lock into silos of ICUs and EDs and all that stuff that we can easily do and actually share information to move forward. So, that's really exciting to hear. And I think the listeners need to take away that shared governance is a piece of the culture, it's not a thing you do. And to treat it that way.
Karen:
Well, one of the things for me too, being at UCLA, we have a lot of resources. So it's probably easier for me to reinforce all of this. I can think that people in a critical access hospital, or people in a smaller community hospital, this would be extremely challenging, because we have staff who come in to work on committees and who... You know what I mean? We fund that. So when you come in to work on your professional practice council, we underwrite that, it's not volunteer time. It's part of who you are as a nurse and our organization, the role that you have on that committee. So it's compensated. That can be a big ticket for a small organization.
Dan:
Yeah. But I think what you also mentioned is the returns are worth it as well. So, you see these changes and adaptations in real-time with that sort of work. So the investment isn't just about dollars, it's about also this return of better practice and a culture that can navigate through even the toughest time. So it is that balance, but that's also a good point, you have to resource it as well.
Karen:
Yeah. But I think the other piece that you just brought up too, is the value prop. So that nursing officer who says, I need to do this, and this is what I need to make it happen, she or he has to be willing to say, and this is going to improve our CLABSI rates. This is going to reduce our falls. This is going to improve our patient experience. And put your money where your mouth is. Own that metric, that you know will be impacted by your investment.
Dan:
Yeah. I think that's a great point. Going along those lines of resourcing, one of the things I've heard over and over is, well, we didn't have the staff to actually do this. And so I know one of the things that you're passionate about is this future of staffing strategy. And one of the things I've been saying is, and it's a provocation, but it's also true. You'll never, ever, ever be fully staffed ever again. And so you have to think about staffing differently. And that doesn't mean you won't have enough people to do the work, you just won't have the same full-time employees to do it. And you may have to have flexible float pools or external labor, new roles, or those type of things. So we have to think about staffing, not like we did pre-pandemic where you just throw nurses at the problem, but to really think about this different way of work as the entire country and every industry is rethinking what work means. And so would love to hear your thoughts on how you're thinking about strategy around staffing.
Karen:
To your point, we have to understand what is it we need. And the second piece is nurse scheduling since the Baylor plan and the shift to 12 hour shifts, which has been a very long time now. We've gotten really rigid, at least in the inpatient side, to the point where, I've been in environments where people will say, oh no, people can't work part-time and to have 12 hour shifts, they have to work three shifts. And it's like, that makes no sense. You know what I mean? So it's like, wouldn't you rather have somebody who can give you two twelves a week and know that they're going to come in and they love their job? And that pre-pandemic was even a hard sell. Today what I think we have to do is I think we have to look back on history. I had a nursing history professor who taught me there has always been a nursing shortage.
Karen:
And I think time spent in Florida for me as a CNO, Florida on the coast with snowbird deals with nursing shortages every season. So you learn some ways to become very resilient and self-sufficient. And so I think that taking some of those things I learned early in my career and looking at what we've realized with the pandemic, I think as leaders, we have to challenge ourselves to let go. I think we have to understand that we're always going to have some level of vacancy, and how do we mobilize for that? So for us here, for example, we took the time to recalibrate our positions. And in doing that, we identified that because of leaves, increased absenteeism and all sorts of other changes, vacancy rates, turnover, et cetera, we had what we would call an operational vacancy that was much higher than the actual vacancy that you would find in human resources in their statistics.
Karen:
So what we did was we crafted a strategy with finance and we put those positions on each of the individual units rosters so that they can essentially overhire to accommodate orientation, turnover, absenteeism, prolonged leaves, et cetera. We've been doing that since July with good effect. And so while it's always challenging for a financial office to say, okay, I get this, yeah, this makes sense. For us it's allowed us to keep the pipeline greased. That's a strategy that we put in place last year and we plan to keep ongoing so that we are always able to interview the best and the brightest. So in keeping with that, we've also looked at how do we partner differently with local schools, whether it's schools for nursing assistants, scrub techs, RNs, it doesn't matter. How do we partner with them differently to almost create an apprenticeship while they're still in school and they make their transition over to an acute care environment like UCLA, or any other hospital for that matter?
Karen:
How do we start to formulate relationships and modify things that we've always done that way so that they help us lay in a way to get to the level of experts we need in our organization to care for our patients, regardless of the role? So, those partnerships are really important. Other things that we've done is, what do you do for a float pool? Do you have your own float pool, or do you rely on travelers and other third parties to help supplement your staffing? We've had a commitment since I've been here to build a float pool that can support our regular absences, as well as backfill a percentage of our leaves. This absolutely helped us when it came time for COVID because we weren't as reliant on third party agencies to find nurses.
Karen:
So our traveler numbers while they popped up a little bit were well below what probably many of our other facilities in our area and nationally were running. So it's how do you become more self-reliant? And how do you start to anticipate needs? Other things that we've hardwired as well is we've got a slew of nurses who are in the tail end of their career. And you know what? 12 hour shifts in our environment are exhausting. And they've had comments like, if I could just do eights, or if I could just do sixes, I could do this and I won't need to retire. So we've created break shifts and other shifts of time in the course of a 24 hour day where people can pick up six or eight hours, and contribute to their unit in a very meaningful way by taking patient care so that other people can have breaks, or do whatever they need to do, or to take on admissions while the rest of the nurses are caring for their patient population. So everybody's satisfied, and we still have nurses with experience.
Karen:
We stand to lose a lot of institutional knowledge here because a fair number of people put off retiring when the economy got a little soft a few years ago, coming out of COVID people who had planned to retire in the past, and now at a point where they'd like to retire, and then we have the great resignation built on the people who have just tired, or don't want to practice anymore. So it's a balancing act, I guess.
Dan:
I would say a lot of the flux within the day to day operations are what you mentioned, planned leaves or a trended absentee based on sick calls or whatever it is. And so that float pool makes a lot of sense and then supplementing these unexpected pieces with more flexible work and different levels of FT, it doesn't have to just be a 0.5, a 0.8 and a 0.1, you can do other things and to be open to those things. And I think, one of the other pieces that I really think helps UCLA as well is that you have such a great new graduate program as well. And you allow new graduates to start in almost any specialty area that exists there. I started as in the ER, I know I interviewed at the CT ICU, and I just remember how amazing that was when all my faculty and all my other cohort of students are like, well, we're going into med-surg. And I was like, that wasn't my passion. If I would've gone to med-surg, I would've quit nursing after year one probably, just because it just wasn't who I am.
Dan:
I'm an ER nurse all the way through. I figured that out and that's still in my blood, but I think allowing for people to have that passion and find it early on in their career allows for them to also stay with the organization longer, because they don't have to pay their dues necessarily in that way. That's also a talent strategy that other systems need to start adopting too.
Karen:
And I think paying your dues, it's like eating your young. Why? If somebody has a skill set and the interest and they're trainable, why can't they start anywhere? And med-surg has become its own specialty now. So to think that having somebody work med-surg is going to teach them anything about a particular intensive care unit, or some other location in the hospital, might be foolhardy. You know what I mean? We might just be living off an old tradition, which is dangerous. And then we need to really pay attention to what we let go of, because sometimes we let go of things way too soon. And one of the things that always comes to mind for me, because I was one of them, was the three to 11 shift. I couldn't think of a better shift to work in an emergency room, Dan, than that when I was doing my clinical time. And we eradicated that. And I think we didn't study it enough before we had it go away and we lost a lot.
Dan:
Yeah.
Karen:
And one of the biggest, funny story having worked three to 11, we always used to give PM care. We'd tuck everybody in, brush their teeth, face, back rub, all that kind of stuff. I remember my first CNO job, I went upstairs to help on a unit and I said, I can at least help everybody get set up for bed. And they looked at me and they said, what are you talking about? And I went, don't you tuck everybody in? No, we lost it. The [Kanban 00:26:18] was so important. We lost it. I don't know that we've ever gotten it back consistently.
Dan:
Yeah. Three to 11, that's the busiest time. Why not up staff or have people that love that? I was night shift for a long time, and right around 2:00 AM you're bored, there's not a lot going on and so, but you felt, oh, just craziness up until then. So how do you staff up on some of those surges and things and just, yeah, again, we have to question, what did we get rid of and what are we not doing and where were some of these innovations working in the past and can we go back to them too? And I think that what's old is new sometimes, and we get rid of things and I think exploring those are really good. So the last topic I wanted to chat with you on is your work with Vizient. I know you're doing some great stuff related to healing and supporting the profession. So I'd love to hear more about what you're up to with Vizient.
Karen:
Well, we all know that as the nursing shortage approaches, or I would say we're waiting in pretty deep right now, we have national benchmarks that a lot of us use every day. And the tough part is, is a nursing shortage when you start to look at productive hours per patient day on an inpatient unit, if you have a nursing shortage and are unable to staff, that's going to drive down your hours per patient day that you're actually being able to provide. And in turn that could actually drive productivity benchmarks across nursing down in a not so good way, because they wouldn't really be reflecting what a healthy cohort of hospitals are doing with their patient populations based on acuity. It suddenly becomes a tumble as the staffing falls away. So one of the pieces that's really important for me is to get the word out, to remind people to watch their hours for patient day and understand the impact that the shortage may be having on them.
Karen:
And in turn, start those conversations with finance officers and with C-suite members and even your colleagues to say, you know what? I anticipate this is going to drop a little bit because we're not able to staff, but for me to maintain adequate staffing, I need to maintain my hours per patient day, where it is now, not where it may tumble to. So please know that I will continue to recruit. I will continue to do my best to maintain the staffing ratios and things like that, or the staffing requirements for my patients, despite what the benchmarks are telling you.
Karen:
And I think we all know that as people yet to C-suite levels and other levels, they're handed reports on a monthly basis or weekly basis depending, and those are some of the things they watch all the time, because labor is, of course, the largest expense in any health system. And so the first group that always gets looked at is nursing because we're the largest group. So helping prep our finance officers and our other members of the team at that level, that while this is anticipated, it is not something to hang our hats on, we need to go back and look at numbers from 2019 and think benchmarks from 2019, or before, so that we don't make a fatal error in our staffing and essentially prolong the nursing shortage, because we would create its continuance by accident, by responding or reacting to the numbers.
Dan:
Yeah, I think that's a good lesson to have around the benchmarking piece. And I think a lot of people try and achieve the benchmark, but that's just achieving what others are doing. And so if you have an idea of innovation, you want to exceed those benchmarks, or blow up those benchmarks, or create new metrics that show different things. And I think that's a key to being nimble and adapting and not just trying to be like others, because there's definitely nuances in all of that stuff like you mentioned, and the benchmarks are one data point, not the data point. And so I think rethinking those pieces is a key leadership tactic.
Karen:
Right. And the thing that nurse leaders need to remember is we are the experts in that, not finance, no one else. We need to understand what we need to get the job done. And then we need to keep people cognizant of that so that we continue to provide the level of care needed for our patients.
Dan:
Well, Karen, this was awesome. I really appreciate your time today and chatting through all of those things that are just so important for us to lead out of the pandemic, the innovation, and just the amazing culture that UCLA is, that is in part because of your team's leadership. And so, one of the things we like to do at the end of the show is provide a handoff, that one piece of information, or that one nugget that you want to share with the world that they may take away and implement tomorrow. So what would you like to hand off to our guests?
Karen:
I think, especially for leaders, being present, and for all of us, being present, because I think it gives us the opportunity to actively listen and put yourself in places where it's important to listen, rounding meetings with colleagues, meeting with staff, so that you can be your authentic self. You can listen, understand and take what you're hearing back and use it to help provide better leadership. There's nothing like listening to your staff.
Dan:
Yeah. If people want to reach out or learn more about your work, where's the best place to find you?
Karen:
Oh, UCLA, KGrimley@mednet.ucla.edu.
Dan:
And LinkedIn, I know you're on LinkedIn every once in a while as well. And so check out UCLA, especially for those new nurses looking for roles, experienced nurses, UCLA is just an amazing place. And I was only there for a year, but I credit that year as probably one of the most catalyzing experiences for my entire work. And so I just have so much respect for you and your leadership and the organization as a whole. And just really appreciate your time on the show today.
Karen:
Thank you. It's my pleasure, Dan.
Dan:
Thank you so much for tuning in to today's episode of The Handoff. If you liked what you heard, please consider leaving us a review on Apple Podcast or wherever you listen to podcasts. You can also subscribe and receive new episodes at www.thehandoffpodcast.com.
