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Episode 69: How Johns Hopkins manages its contingent nursing workforce

April 26, 2022

Dan:

Hey, everyone. Welcome back to The Handoff, a podcast about healthcare innovation. Today, we have Laura Fricker. She has an amazing job that is unique to many health systems in building its own internal, flexible labor pool and travel company. And so Laura, we're excited to chat with you and welcome to the show.

Laura:

Hi. Well, thanks for having me. I work for the Johns Hopkins Health System. It's a huge umbrella, but a little bit different glint. So we are not with the university directly as much as we are with all the hospital systems.

Dan:

You do have this unique role within the health system. Can you tell us a little bit about it and how it came to be?

Laura:

Sure. So I'm the executive director for Intrastaff, which is sort of a two-sided entity within the umbrella of Johns Hopkins Health System. So if you think of the history, we were started a little over 30 years ago as an internal float pool for nursing and started that way sort of in fits and starts. And then six, seven years ago, we really picked up the more of the contract work and really started an increased hiring as a separate staffing agency. We are a licensed staffing agency. So we have our own employees that we have as temps within the health system.

Laura:

But then a couple years ago, 2018, we picked up the MSP for nursing for the health system. So now we manage all of the agency contracts and really all the agency throughout the system, clinical and non clinical. So we're the one stop shop, right?

Laura:

So the advantage to the health system is that you can get all the data from me. All temporary services come through us, whether we are the primary hiring agency or whether it's an agency coming through us. We're a one-stop shopping for managers to understand what their use is, what the total cost is to the health systems. Great for leaders. And then we manage all the same compliance all the way across. So all of their compliance data is with us, right? So it's just, like I said, one stop shop. You can get all your information in one place.

Dan:

Now, there's a lot of external organizations that also offer those services. And so was the thinking that you could kind of be more efficient if it was internally managed, then kind of outsourcing it? And I know that's something our listeners are wrestling with coming out of the pandemic as well.

Laura:

I talk to a lot of people about that, absolutely, every day. The answer is yes. My whole job is to, of course, manage all the temp services. But a big part of my position is to really look at the market and to look at the market in a fashion that is a bit more vendor neutral and more advantageous to me as a health system.

Laura:

So while I understand that everybody needs to make a dollar in the temporary staffing services, every agency, they have to make money to survive. I mean, that's the truth of that. But you can manipulate things in such a way that you can control rates. You can create a competitive environment among agencies to find market rate that makes sense in this market right now, in this atmosphere. You have at least a sense of control, right?

Laura:

And there are times when I feel like if I can lower rates, I do, or I'll throw a rate out there to see. You go fishing sometimes just to see what'll happen. And nine times out of 10 we're right on. Right? I'm actually quite a bit lower than what some of the agencies want me to pay. You got to keep the communication open with the agency groups and really build good relationships, but also do your own homework. Right? See what's out there. Really understand your area of the country.

Laura:

I am Mid-Atlantic, obviously, and I don't want to compete with New York. I don't want to compete with California or Texas, those high priced areas. Oregon went up so high last year when they were really experiencing some troubles and I want to pay a fair price for where I am.

Laura:

So really working on that, understanding the market then we can build a price point that makes sense for our institution. It helps to be internal because I know where the pain points are. Right? So if I have a unit that needs to be stood up right away, I can manipulate pricing to have that happen right away. Or if I have something where I really don't have that need for another couple months, I can manipulate that pricing too.

Laura:

So it's about how fast you could fill it or how fast you need to fill it and being internal I know what that is for real. Right? I know what the plans are. I know is this unit coming? Is this unit going? Do they have a new surgeon? And now I have to open four beds tomorrow. You have an insider view for what's happening within the institution. And that really helps me manipulate and keep things clean.

Dan:

Yeah, that's great. And it sounds like you have a better pulse on the supply and demand equation, which is one of the biggest issues I think with the staffing in general across the country is we sort of know generally where the demand is, but it's not as specific as if you were within the system. And then we sort of know where the supply is, but not as much as if you know your own market. And so it sounds like you just have that better pulse to really make that connection, which eventually drives more efficiency and the cost down within the system.

Laura:

Right. Well, and then on top of that, I think also for leadership, knowing that I'm there and this is what I do. When we do have to drive rates up and we have. I mean, we've been in the two hundreds like everybody else. When we have to do that, I feel like there's some level of understanding and belief that's the right thing to do with the time, if that makes any sense. So you don't feel ripped off all the time. You don't feel like, "Oh, who's manipulating me now?" You feel it's more of a controlled burn.

Dan:

Yeah. That is a very relevant statement in my current world. So yeah, I totally get it.

Laura:

Yeah. But you can make these things very deliberately. So when I have had to go up in price to say, "Hey, listen, this is what I'm seeing. This is what we're going to do. This is how we're going to manage the market right now with plans to come down again. So it really helps people to understand and keeps leadership, keeps the finance people, keeps everybody so that they understand that we're flexing to the market, but we're also going to respond as the market comes down. Right? So it's a give and take, it's back and forth. Software hates it. But here we are just kind of figuring out how to manipulate things so that we get the best deal at the right time.

Dan:

Yeah. I like it. And it is a more dynamic way to solve for it than some of the other places that I've seen which is we're just going to cut rates and we're going to just do this. We're going to eliminate this thing. Those are all sort of linear solutions to a complex problem and aren't going to be long term sustainable.

Laura:

Correct. Well, and I think the lessons learned over the last two years are really going to pay forward. So the understanding of what it takes to learn about a market, understand a market and to watch it will help us later. So this pandemic, we always joke in the office, this is my first pandemic. I don't know. So who knows what the future brings in another eight or 10 years. There could be another pandemic or there could be some other crisis. And really, if you learn from one crisis, you can hopefully extrapolate that lesson to the next.

Laura:

And that's the goal here, right? We want to be able to understand and know the market so that if things happen again, we can flex with it and we can kind of manipulate it to our advantage.

Dan:

I think that's a great point. Speaking of the pandemic, we have learned a lot and we've learned what possibly works, what doesn't work and the sustainability of it. We're seeing nurses specifically... For the first time I was talking to a group of deans the other day and they for the first time in their entire history as deans, they're having their new students come up and say, "How do I get into travel nursing when I graduate?" That really hasn't been part of the conversation widely in nursing school. So what are some of the things that have changed since the pandemic and what are some of the trends you're seeing?

Laura:

Well, of course, yes, everybody's traveling. Everybody wants to travel. They think that's an instant paycheck, right? And in some cases it is. I think people also have to understand that travel is hard, that it takes a special person to be able to flex into a role that you've never seen. People you don't know, and areas are different. Baltimore is a challenging area if you don't know where to live, where to be, how you want to manage a new area.

Laura:

So we've had some failures with some young people who have come in and thought that this was going to be some sort of easy road and it's not. Travel nursing is challenging. Certainly, I think if you talk to travelers, it's fun and challenging. But if you're not the right person, that's not fun, right? It's about being a flexible person that can really thrive in new situations.

Laura:

It's for people that like change, and that's not the case for everyone. In terms of what I see in nursing, I mean, nursing has really changed. I'm a long time ICU nurse. I mean, I did it for 26 years at the bedside charge and all of that, and nurses are viewed differently. It certainly, I think if you look at nursing careers over 30 or 40 years, the technology has changed so much that nurses are experts now.

Laura:

Not that they weren't before, but the level of expertise and a level of having to understand complicated systems has really changed. Right? So I think if you're looking at somebody who's an expert in technology and expert in safety and all the pieces that are now a part of patient care, it's a different person you're talking about than 40 and 50 years ago in terms of just knowledge base and having to continue to learn and to move forward.

Laura:

In a lot of ways I think nurses were undervalued, I think, as professionals. And I do see this as the opportunity for nurses to be paid in a way that a professional is paid and to be respected at a level of understanding that this is a very technical profession in many areas. You have to be a smart computer person. You have to understand multiple systems. You have to understand political climate all while holding somebody's hand. It's a really complicated job and I do think that as the dust settles here, I think nurses will be valued at a different level than they have in the past.

Dan:

Yeah. I resonate with that as well. What I'm seeing too is in general, nursing schools are producing sort of that generalist sort of that kind of equivalent of a med surg, tele sort of generalist role where the market is actually demanding more specialists, ICU, level four NICU nurses, quaternary, OR, those type of things. And that's just not entering the market as fast as I think the need is within the system. Do you see that as well?

Laura:

Maybe, yeah.

Dan:

You can totally go against it.

Laura:

No, no. There will always be a need for all levels of nursing. Right? And of course you do the reading about what hospitals will be in 50 years. They're just going to be ICUs and ORs. Everything will be taken care of at home. And so the med surg tele nurse will be viewed a little bit differently in that time. No less important and no less technical. So it's sort of interesting. There's need for across the board. Right? What I don't like out of nursing schools, and this is my personal opinion is that I don't like nursing schools that are trying to produce leaders from the get-go.

Laura:

Leadership, you'll become a leader if that's who you are, but you first need to be a nurse. If you're coming out of nursing school, you need to be a nurse first. Like I said, that's the old lady view and that's sort of how I feel about that. But I really think that you got to learn the ropes. You got to be there. You got to stand on the ground and be with a patient and really be a nurse before you can claim that skill. It's a whole learning thing and nursing is a beautiful profession and certainly something I've devoted in my life to. But it's also very challenging and there's a lot to learn.

Dan:

Yeah, for sure. And again, it's back to that supply and demand piece. In other industries, it's the widget that's being made, meeting the needs of the people out there. And of course nursing and healthcare professionals are not widgets, but we can learn a lot from other industries about how market shift and the product that comes out and nurses are a product of their school, and so we need to make sure that's matching the demand from the people hiring them. And I think we have some work to do there probably.

Dan:

We touched on this a little bit earlier, but what advice do you have for listeners who might be wanting to stand up a program similar? I know in multiple organizations I've worked for, we've toyed around with whether it's local float pools or flexible labor, or an entire travel organization. What are some of the things they need to think about before they take the leap?

Laura:

It's level of commitment really is the question, right, that I'm talking to. I had the opportunity to really touch base with a whole bunch of people who are doing exactly that right now. I would say to a man, they've been surprised what resources it takes to do this. It's not something to be taken lightly. It really is a whole program. And you can start from wherever, right? If you want to be a staffing agency as we are, start there, but understand that it's not an easy thing to do. You can't just say, "Tomorrow, I'm going to be a staffing agency." Right? You got to do the whole thing.

Laura:

You have recruitment, you have staffers, you have finance, you have your payroll people. All those functions need to occur in order to be successful. So you have to go step by step by step. We started as a float pool probably a good place to start sort of as an internal float pool is how we started. But it's taken 30 years to get here. We have a lot of technology. The technology costs are very high. We have software for our staffing payroll and we have software for our recruitment. We have stuff we have on the backend of our recruitment software that helps with texting.

Laura:

We're looking at new recruiting techniques and that part's very expensive and takes a lot of time to be this little local expert in what type of technology do I need to run this business? The resources are extensive that you really need to be prepared to commit to the project.

Dan:

Yeah, I think that's a good point is it's not just put a person and start recruiting nurses. There is a backend. There's credentialing. There's marketing. There's off-boarding. There's oversight and quality. There's addressing poor practices. There's all kinds of stuff that you need to sort of stand up, and I don't think people get all the complexity of it.

Laura:

Correct. And the numbers are so high especially now we started off with couple hundred contracts. When you hit a thousand and you never thought you'd get there and then you hit 1,500 and you think, "Oh my gosh."

Dan:

Yeah.

Laura:

And then you're staring down 2,000, you're thinking, "What? This is 10 times what I ever thought we would do and how are we doing this?" You got to keep renewing processes and looking at efficiencies. Do I need more people? How is my software keeping up? All those pieces that all fit together to make the product, it's surprisingly complex. We have a lot of people that try to pull our business apart and say, "This is what you should be doing, or this is how you should be charging."

Laura:

And it gets so complex after a while. Most of them throw their hands up and say like, "Looks like you're doing pretty good." And you're like, "Yeah, we're fine."

Dan:

Yeah. I love that. Well, I mean, with 2,000 contracts, so you're in like the top 10 staffing size in the country too, which is pretty impressive in its own right. I want to flip also to the other side of the equation of the nurses or the contracts that you have, the people working those contracts. What are some of the unique things that you can offer them managing it in house? Do they get better benefits or do they have more flexibility? What are some of those perks that they get?

Laura:

We are on the cusp of doing more of a national hire portfolio sort of thing. But really right now we're local hire. So working for Intrastaff has does have benefits. We have benefits. So there's that, right? We certainly have all those sorts of things. It's nice because it's the same sort of thing as any insider review, right? So I'm going to make sure that my nurses have opportunities that might not be able to be easily presented to a travel.

Laura:

So for example, and this happened just as a pandemic was happening, our mother-baby area was very short. We had couple of last minute like today, I need somebody, kind of situations. And next week, I don't know what we're going to do. Certainly, not enough time to really recruit and find mother-baby nurses. So we took some of our strongest med surge tele nurses that had an interest and trained them into the area.

Laura:

And that's the kind of partnership with nurse managers that you can't do unless you know everybody, right? I know the nurse that's going in for this opportunity. I know the nurse manager. I know what we can do. We did the same sort of things in pediatric area. We had some adult people that wanted to experience pediatrics and how can we bring them into a pediatric room and give them training opportunities?

Laura:

So being local, being on the ground, you have those conversations that you wouldn't... When would a med surg nurse ever get the opportunity to go work mother-baby for a couple shifts and see if you like it? It was very carefully planned and it worked out really well. So just those sorts of opportunities, you can't present to a travel company, right? That's local and on the ground. And that's other stuff. You work for Intrastaff, that becomes a part of your tenure at Hopkins if you do go in permanent.

Laura:

And in terms of the health system, the pandemic numbers are really screwy, but pre-pandemic, we were converting about 50% of our hires into perm roles. So certainly a great recruiting tool for central HR. So we were able to pull in a lot of people for them. And we work across the board. So I'm not just talking about nursing, I'm talking about warehouse, housekeeping, dietary. We do all of those pieces. Radiology, every piece. Clinical and nonclinical, admin support, all of it. And like I said, there are about 50% conversion. More difficult to measure right now because of all the travel.

Dan:

I've often thought about either internal or even potentially external opportunities to also use as a career development tool. So you can identify high performers and then move them around the organization to see all the different aspects and that can lead to your next formal leadership roles, your CNOs, because they have the opportunity to touch every part of your organization and grow as a leader. I think that's a really kind of unspoken, unheard of sort of benefit of the travel world too. And externally too, you can go work at Johns Hopkins, you work at Stanford. These huge academic medical centers and learn the best of the best.

Dan:

And then when you're ready to settle down and do your next thing, you've now seen the best practices, the hardest surgeries, the, whatever it is, and you're sort of like a special ops now of nursing. I think that's something that we just don't talk about enough.

Laura:

That is absolutely one of our future focuses is to really start looking at recruiting the future leaders and people that want to come for a year or two. What kind of program can I build for those future leaders that from a small area? Maybe they come from a relatively small hospital. Maybe don't need a master's degree to be a nurse manager or nurse director at a director level. Come in and learn about leadership, really understand how that works in a larger system and then take it home.

Laura:

And really it's an opportunity, like you said, to differentiate yourself in your career and move forward when you get back to where you want to live permanently. Right? So there's lots of opportunity. And that's of course what we try to offer internally for our temp hires is exactly that.

Dan:

One other piece of the flexibility equation is the length of shift. Are you guys thinking about different shift lengths? Even down to two to four hour shifts instead of kind of bucketing people into eight, 12 or beyond?

Laura:

So possibly. We haven't done much work in that as a temp group because I really am limited to just temporary staffing. I know within the health system, there's multiple strategies.

Dan:

Whole conversation.

Laura:

Absolutely. And I'm sure timing is one of them and lots of internal, like many systems right now. Same sort of stuff. How do you offer opportunities for your perm staff? And it's not just money. Right? You know, certainly everybody's gone up internally. Like I said in the beginning, I think nursing is finally being recognized for the technical profession that it is.

Laura:

Yu talk about Maslow and the hierarchy and all of that, we got to get to self-actualization here. Right? We got to really go all the way. So all the cool things that they're offering in terms of leadership opportunities and moving within the health system, trying on different hats. I think that as we move forward, people are getting to understand that flexibility is really important and giving people opportunity is really important, and that one size doesn't fit all.

Dan:

Yeah. And I think as the newer nurses enter the workforce, they're expecting something different than what has been offered in the past. So I think they'll drive some of that and they'll vote with their feet like they have been through the pandemic to say, "If I don't resonate with your values or the opportunity to not be thrown on the worst shift at night for 16 hours with the worst patients, I'm not going to work there, and I'm going to go somewhere where that's going to value me differently." So I think that's going to be an interesting trend. But as you think about the future of staffing and workforce, what do you think the future holds for us? Any predictions?

Laura:

Well, I do think a larger percentage are always going to be travelers, right? I mean, that's something that everybody's talking about across the board and that's going to force hospital leaders to really say, "Okay, what does my work force look like? If certain percentage is always going to be temporary staffing, how does that look for us and how can we take advantage of that? I mean, temporary staffing is such a dirty word.

Laura:

People don't like it. Contingency staffing or however you want to call it, but really it's the most flexible workforce you can have. Right? It does come with costs. But you can use it in a way that helps you or you can use it begrudgingly, right? I mean, use it where you have to use it wisely and it can actually be of great advantage. And like I said, we are able to keep cost down. I mean, my average charge rate for an internal Intrastaff nurse is about half. Actually a little bit less than half of my average travel rate.

Laura:

And that's because I manage it locally and that's the way to do it. Keep the prices down as low as you can. I don't have any stockholders that I need to manage, so the money goes to the nurse and I really run a tight margin just to pay for our software and our people and hopefully my dinner.

Dan:

Right.

Laura:

But that's important to understand that temporary staffing isn't going away. It won't be as big as now. It won't be the beast that it is now, but it is here to stay. And I think that leaders really need to think about, "Okay, so it's here to stay. How do I make it work for me?"

Dan:

Yeah. I think that's a good point. And it is here to stay. So flexible labor, however, that is, internal, external pools, short term, long term contracts is all part of the equation now. And those productivity numbers and that kind of stuff are sort of not going to cut the bait as we move forward. So I think as health system leaders, we have to rethink, how do we do those equations and how do we really think about this differently? I think it's going to be a lot of fun to try and predict that.

Dan:

The other thing I wanted to ask you about is there's a lot of new entrance into the staffing world. I think they saw the opportunity from a business perspective. There's a number of new companies, new technologies, new thoughts in this. And we don't have to name names of any of them, but what do you think are some of those disruptions that you are excited about that might help make the staffing world a little bit more efficient or a little bit different?

Laura:

I mean, you nailed it. I mean, that's what the pandemic has pushed a lot of this technology forward, I think faster than a lot of people had intended. The nursing boards that are all out there are... Agencies love them, nurses love them, internals don't like them. We don't like them at all. Talk about necessary evils, but anything where we're all comparing rates against each other, all that does is drive rates up. Right?

Laura:

So on a personal level, I think that's sort of hurt the industry on our end. And I believe in paying good price for a good nurse. I have no problem with that. But to really build in competition between health systems is a little bit challenging. And I get it. That's what happened and that's not a problem. But that's not my favorite part of it.

Laura:

The other disruptor that I see that's really cool is this... And a lot of people are coming out with this is more of a... I don't know what to call it, sort of a concierge PRN staffing services. The last minute staffing. So that technology is really cool. There's some great companies coming out with some different ideas there.

Laura:

My only caveat, my worry is compliance. You got to make sure that the people standing in front of you are fully compliant, that their drug screen is fresh and that all the stuff that we know that their licensure is up to date and that the quality is there. That's my only concern and it goes back to what you said earlier. Nurses are not widgets.

Laura:

So if you have a firm that's a technology firm, which I think some of them really start as technology firms, and then they think, "Oh, we can disrupt the healthcare workplace and they do." But they need to have some healthcare professionals on their team to say, "Whoa, whoa, whoa, whoa, whoa. An ICU nurse is not an ICU nurse, is not an ICU nurse." So to say dial a nurse doesn't always work. You got to be careful with that.

Dan:

I mean, I heard that as well when I joined the staffing world of couple years ago and I kept hearing the disconnect in California, a big institution who said we're asking for OR nurses. They're giving me OR nurses, but we need the nurses that have done the one surgery that this one physician has done in our institution or at least know how to do those kind of more complex things. And it's not all the same. I think that extrapolates across all of it. We need to be more diligent or effective in measuring nurses competencies, their skills and then their career passion and match all of those to the jobs out there because that's where you'll find people who are excited to go in there, who have the skills to do it and really thrive in the environment. So just throwing two feet in a heartbeat out there.

Laura:

Correct. Absolutely. Like I say, there are people that are attracted to that high dollar, and those are not necessarily the high performers. Right? And quality is number one in, I mean, patient care, patient care. So we say it's about the fill, but patients come first. And like I said, they're not widgets. You just have to be careful that you get the right person in there. That's my concern with some of the PRN last minute dial in, or sort of systems. They'll tell you that their compliance is up to date and perfect, but people just need to be aware and be careful.

Dan:

Yeah. I think there'll be more scrutiny around that and I think there'll be both technology, but also I think the boards of nursing need to evolve a little bit there too to help create this moving portfolio that sticks with the nurse. And I think there's some cool things coming out of it. Actually NCSBN having that unique nurse identifier and how do we tie some of these things back to that so that there's visibility with eyes wide open to practice and quality and those type of things.

Laura:

It speaks to a national licensure really. I mean, the whole biz. I know .

Dan:

I live in California. I have one of the slow boards on the planet. And so 13 to 15 weeks to get a license by endorsement is just not an effective way to have a profession come in and help or to manage the safety of the public. So

Laura:

Yeah. No agreed. I get it. They're different everywhere. And states do need to have some control over their system. I totally get that. But there should be some baseline somewhere that we can look at and review.

Dan:

Yeah, agreed. I think your message of this is all about patient care and quality care is a good place for us to wrap up on. We talked a lot about different topics of starting your own internal program and the future of work and what nurses can do, and some of the flexibility in their roles. Out of all of that, what would you like to hand off to our audience and leave them with that one nugget as we wrap up here?

Laura:

I guess my advice is like, we really have to look at employment overall, and that's working in the temporary world. So people should be flexible and really think about building new spaces for creative employment situations. So that way we can attract nurses across the board. One size doesn't fit. So you want to make sure that you develop a system where nurses are comfortable coming in and out. So you want to have a mix of full time, part-time, float, temp, traveler, all of that and make it so that people can come in and out of that. Not even in and out, in and around that system, because you don't want them out. Right?

Dan:

Yeah.

Laura:

You want them to be able to navigate your system as their life circumstances change to a way that helps both this health system they're working for and themselves, right? They want to move forward professionally. They need to take care of their families. All of those pieces need to fit together to keep active employment. So it's really about understanding that employment is changing, that we need to be flexible and that there is opportunity if we look really carefully at how we pull jobs apart.

Laura:

A good example of what you just said is wire shifts, eight, 10, and 12 hours. Are there such things as maybe four hours just so you know the patient, right? Or what does employment look like? So it needs to be much more flexible and open to some of those arrangements that seem so foreign in some fashion, but really actually could be the advantage, not just to the nurse, but also to the health system.

Dan:

Yeah. I think rethinking employment and flexible work whether they're full-time or not, I think is the key takeaway there. So Laura, where can people find you if they want to learn more about Intrastaff or get in touch with you to learn more about what we talked about today?

Laura:

Well, my email address, I'm sure, you'll have it on here somewhere in my bio. Certainly welcome to find me through Johns Hopkins. I do work for the health system. And I'm on LinkedIn, so please friend me, say hello. I love connecting. I love seeing what other people are doing. I think there's so many innovative ideas out there. I love to have the conversation. Tell me what you're doing.

Laura:

Now, we can all learn from each other. I'm interested in really building a better network of systems that are similar to what I do because I think that as we learn from each other and we move forward, we can really build really good and cool systems and figure out how the technology can work for us. And would love to talk to people about best practices and their experiences especially over these last two years.

Dan:

Awesome. No, that's great. And we'll put that in the show notes so people can see that and reach out. Thank you so much, Laura, for being on the show today. It was great to chat with you and learn more about your work. And looking forward to seeing how you disrupt employment in the near future.

Laura:

That's the goal.