Lauren (00:00):

Welcome to today's academy session. Just to clarify, especially for those of you folks who were with me earlier this week, this is not a nursing catalyst session, but I'm really excited to be hosting Betty Jo Rocchio, who is the SVP and Chief Nursing Executive to have a discussion around a the need for care transformation and why that's really a mandate for nurse leaders and other leaders of clinical care delivery, but also and more crucially how to get there, what is on Betty Jo's priority list and really what she and Mercy broadly are thinking about from a workforce perspective to really enable that kind of care transformation. So just to give you some context as to who you have on the line here with you today, if you are not familiar with Nursing Catalyst is that my name is Lauren Rewers, I'm the senior research director for that group that we act as a nursing innovation incubator in which organizations from across the country come together share outcomes among things that they're working on like virtual nursing.

(01:09):

We put together benchmarks around span of control and others really with the belief that we can all push forward on transformation if we do it together. And so in that spirit, as I mentioned, absolutely thrilled to have Betty Jo here today for many reasons. She is currently serves as Mercy's SVP and Chief Nurse Executive as I mentioned, since October, 2020, and she was previously the chief nursing Optimization Officer and the VP of period operative services for the system. Prior to joining Mercy, she held leadership positions in the Mount Carmel Health System in Columbus, Ohio. And in addition to all of that, she is the co-chair leading Mercy's AI efforts for the system. So I'm hoping to leverage obviously both her expertise as a really forward-thinking nurse executive, but also to leverage that expertise in terms of technologically enabled care and how both of those are working in concert in order to pave the fast forward for the next generation of nursing care.

(02:16):

What I'm hoping to accomplish today is really that we will of course have already introduced ourselves, but I'm going to share a few slides that's really about making that case for care transformation more so I know that of course if you're joining us here today, you're probably interested but want to give you some context as to why we feel like it's imperative for health systems to be able to sustain the way in which care is delivered and to really be able to continue to offer that high quality and access to patients that I know that is important to everyone on this line. But after we get to that around the 15 minute mark, I'm hoping to have a conversation between Betty Jo and myself for about the next 30 minutes to set the stage around Mercy's efforts as well as to start to unpack some of those questions I referenced about how technology can enable care transformation and really how to think about managing the workforce differently as well to pave that path forward for the next generation of care.

(03:18):

Lastly, we are going to save the last 15 minutes our time for Q&A. So as you have questions, please feel free to keep them going in the chat. Please feel free to use that liberally. I'll integrate them into our conversation and keep an eye out as we go along and anything we don't address, I'm hopeful that we're going to get to in that last 15 minutes. So please don't hesitate to enter your questions as we go along and I'll do my best to get to as many as possible. So with that, any initial questions about our time seeing a lot of folks introducing themselves, which is wonderful. Nothing for now. So why don't I get to what I promised, which is about the need for care transformation and really to give some upfront context about why now and who is involved in these efforts.

(04:10):

So before I get into that, want to set these stakes for where the data I'm about to walk through is coming from. Every year the Academy does what we call our priority survey where we ask system level executives of large health systems about their priorities, what they feel confident about, what they feel vulnerable about going into the upcoming year. And so as you think about where we're at in 2024, I want to pull up the data from that survey. I think what strikes me, and don't worry, there won't be a quiz on this. I know this is a lot of information to take in at once, but you can see obviously a lot of the tension posed to the workforce, labor costs and care delivery among CNOs, CMOs, CHROs, those folks are probably those who we would expect to be working on these issues given that that is really their day-to-day bread and butter of those roles. What's interesting to me is that as you look across other roles, for example for the CIO care team, admin burden is the number one priority going into 2024, we see for the chief strategy officers strengthening the workforce a huge priority for them as well. All this to say workforce care delivery, thinking about how to leverage workforce in a more cost efficient and effective way on everybody's minds within the healthcare c-suite.

(05:34):

The other point I want to make is that as you look at these different priorities, it almost reflects a tension or I should say a potential tension between different things that need to get done within the system. So in Teal you see more around workforce sustainability. Orange is strict cost to management and then in pink a lot of concerns around access and growth and I think all of these are pretty interconnected. So as you think about, for example, workforce sustainability, cost management is a huge part of this. We're going to get into this in a second, but obviously labor costs making up a huge portion of health system operating expenses, and we also know that especially in many markets, the workforce ends up being the rate limiting factor towards providing additional access or to enable us to keep standing up services that we know are really important to especially rural markets, but anywhere that might be experiencing a workforce shortage.

(06:31):

And so I think for a lot of executives, this feels hard and paralyzing because you want to do the best for your workforce, want to potentially raise rates, think about what bonuses you could offer, but you're also juggling a lot of really tough challenges in terms of that cost and access piece and it feels difficult to figure out how to get at this three-pronged experience, especially when they are either competing or are really exacerbating the other's challenges to start to untangle really how health systems are thinking about placing their big bets such that they're able to address all three issues with a limited number of strategies. I also want to share some context in terms of where health systems are at right now, starting with some good news, which I feel like we don't get a lot about when it comes to the healthcare workforce in the last couple of years. The first piece of good news is that health systems are starting to experience some degree of financial recovery. So if you look at on the left hand side, the margins that health systems are experiencing, the growth and expense is actually while continuing is slowing pretty considerably and that is leading at the same time being combined with in many cases what has increased utilization for providers. That means good news in terms of strengthening those margins overall.

(08:00):

That being said, health systems are not in the place that they wanted to be and are not in the place that they were pre pandemic, even as we are seeing some optimistic signs in terms of that financial recovery. So again, on the left hand side here, pre pandemic seeing margins of around 3.5%, that's still quite slim. It's funny to talk about it as being the era of health system sustainability because 3.5% still feels pretty slim and nerve wracking. Now most systems sitting at around 1.4%. Again, great not in the red, but also that's a pretty fine line in order to navigate as an executive.

(08:40):

Where this is coming from is, or I should say a large part of this story is driven by labor cost. On the left hand side of the slide, you can see a relationship between labor cost as a percent of operating revenue, which is in that blue and on the orange is health system operating margin. Overall, what you can see is really that inverse relationship where as we are starting to see labor costs climb and become a bigger and bigger part of operating revenue more broadly, we start to see operating margins in general start to take a decline. So said more simply as labor costs specifically are increasing, that is having a huge disproportionate impact on the overall health system operating margin even though we know that all kinds of other expenses are rolled into that operating margin. So for health systems, the bottom line is we really have to make a more efficient use of our labor dollars given our need to stay afloat and also to be able to offer additional services.

(09:43):

As you see on the right hand side, as you think about that growth and access piece, workforce is also the number one barrier in terms of health systems being able to grow to take on new lines of revenue, potentially to shore up some of the margin issues that we were just talking about, but really to be able to deliver that high quality care that I know all of your organizations are focused on in the next few years. So if to sum up this slide in one sentence, workforce is premium really has to be the number one focus of how health systems are thinking and when you look at why, I think in order to unpack where this expense is going more broadly, we see that this is the systems are making progress largely due to a lot of the efforts of the folks on this line.

(10:32):

So in terms of the increased RN labor costs, the number one driver of that is contract labor and premium labor expense, especially driven by the volume increases of the pandemic that really necessitated that premium labor and agency staff. And indeed we see that is where health systems are really looking to reduce spend, so of where CFOs and other finance leaders are looking to reduce costs, all of that is around contract labor and that's largely why we've seen a lot of that margin recovery in the last couple of years. Now this is both good and bad news. I mean the great news is give yourself a pat on the back. Nurse leaders and other folks in the clinical workforce space have done a really good job at stabilizing their workforce, working on retention and recruitment such that they have been able to safely wind down a lot of their travel contracts and that's a huge accomplishment.

(11:27):

The bad news is that that is essentially the low hanging fruit in terms of reducing labor expense broadly. Once you start to get rid of some of that premium labor costs, what you're left with is really fixed labor. And so that means really sticky questions around how many frontline clinicians do we need to be employing to deliver safe care? What are the kind of wraparound supports in terms of educators and others that we can give to them, ensure that they're able to deliver that care safely. And so I think this is ultimately good news, but it's a little bit scary if you think about how much we still need to reduce labor costs by, I think we see this again in terms of that stabilization. The other piece of good news is doing a great job on terms of that retention. We saw a huge decline in terms of the retention peaks of the pandemic and in general as we look at the projected outlook, CNOs and CHROs, while still holding some certain reservations in general, feel pretty confident about where they are going.

(12:35):

And the last thing I want to end on before we get into care transformation is other than the shortage and retention issues, we're still seeing a couple of pain points that are continuing to bubble over if not more exacerbated post pandemic than they were in 2019. So as I mentioned, turnover, seeing improvements there. That being said, first year turnover still at a higher point than I think most health systems would be comfortable with. We're seeing that rate nationally upwards of 30% as well as things that are more due to the structure of the nursing role itself. For example, a lot of concern around critical thinking, especially coming out of those new nurses who may or may not have been trained in the middle of the pandemic as well as a lot of concerns around burnout and workload in particular in relation to the nursing role we know has been a big driver for folks either leaving their organizations or leaving the profession altogether.

(13:32):

And so as much as we are thinking about the cost piece, I think this points us to the need for a more transformational change because if you think about the things that are on folks plates that access labor costs as well as the work set of workforce challenges, I think going after each individual one, either looking at line items of labor costs or really thinking about retention specifically is not going to be enough in order to get at all of these issues. What really needs to be changing is the fundamental bedside roles and the nature of the work that they all are doing. And so that is why health systems are really focused on care transformation specifically and of course why Betty Jo is here today in order to speak to obviously care transformation is all well and good. I know that many of you on this line are already bought into the ideas around care transformation, but when it comes down to it, what does that actually mean on the day-to-day, what does a transform care look like and what kind of investments are health systems having to make in order to make that transition as gracefully as possible knowing that that's going to be a pretty long-term investment.

(14:46):

With all that said, I'm going to stop sharing my screen and turn things over to Betty Jo, I have a number of questions for you that I want to get start with and to hear in concrete terms what you're really thinking about from Mercy and then to start to unpack beyond what the potentially transformed care looks like, what are you thinking about, where are you placing your bets as a leader, both in terms of technology and workforce, and then ideally, let's wrap by brainstorming a little bit and thinking about, hey, in 10 years, what is your hope that nursing looks like as well as the roles of the bedside clinicians that you're also working with. One more plug before we get into this. Again, we're going to hopefully wrap this portion of the conversation at 1 45, so if you have questions about care transformation about what Mercy is doing, please feel free to keep those in the chat and we'll get to as many of those as possible. So with all that said before we get into the technology piece, and I'm hoping to spend a lot of time on AI today as well, let's ground our conversation and what Mercy is actually doing right now or in the short term future to deliver care differently. Could you top line where Mercy's care transformation efforts are focused?

Betty Jo (16:07):

Sure. First of all, it's a pleasure to be with you today. This is such an exciting conversation for everybody in the nation because we're all thinking about it a little differently, but placing the bets in mercy on three high level things, workforce, you highlighted the reasons very beautifully, workflows and work environment, those three things in nursing play pretty close together and I'm imagining that our strategy and mercy for our nursing operational plan in the next five years will be wrapped around those three things.

Lauren (16:43):

Awesome. That sounds wonderful. I would love to hear a little, could you give us a few examples in terms of as you think about workflows, what that would really look like or how your either nurses or bedside clinicians in general are practicing differently?

Betty Jo (16:58):

Yeah, I'll give you some just general highlights. First of all, underneath, I'm going to start with workforce Lauren and just highlight generally where we are come to the realization that nursing, the way we pay people and our premium labor costs likely we're going to struggle to manage them without a workforce platform. And so one of the things that's really important is that we introduce data and technology capabilities because you said it beautifully, we have really cut down the low hanging fruit and to get to the more specifics in the right way, we're going to need data and technology to get there. In the workflows work environment piece in enters ai, and I know we're early in this journey, but I would say the definition for me is not artificial intelligence, but augmented intelligence to help and the overall sweeping thing among all three things that we talked about, workforce workflows and work environment is reducing cognitive workload both on the manager and the frontline staff. I think we're going to see a measurability that's going to be needed in cognitive workload before we really introduce a ton of technology because we're going to have to understand how it's affecting the front lines.

Lauren (18:16):

Yeah, absolutely. So would love to dive more deeply, we just talked about the what of care transformation, and I would love to discuss how you alluded to this briefly, but I would love to hear about the role that technology is playing in enabling that change and would love to know as you are thinking about either what has happened in the last couple of years where you're going as an organization, can you speak to the investments that you've made or where Mercy is developing new technologies in-House?

Betty Jo (18:49):

Sure. I think the pandemic while really being hard on us in healthcare and for our patients, I think one of the things that has shown us is what the nursing workforce is really after and they're after flexibility and they are after compensation in some areas, and here's the thing, everybody wants something differently. So having your workforce layers lined out very specifically and your offerings is going to be key. During the pandemic, we paid people in every rich way we could because we were so desperate for staff to take care of our patients. But coming down off of that, really look at what nurses did when they had the ability, they went to travel for schedule, flexibility, compensation and work-life balance, and one of the things that's so important there is that we learn what they want as well as what our needs are. Before we were concerned with filling our schedules and getting our needs met.

(19:47):

To do that today we have to focus on what our workforce wants, so it taught us what they want, developing those workforce layers as the basic foundation and straightening out how we pay people and what our offerings are key. And then in a nurse technology, after we've done all that work, if you put technology into some bad processes, we're really going to speed up probably something we don't want. And then I will say having a workforce platform that's automated allows us, we have 51 hospitals in Mercy, so it allows us to scale our offerings and really expand that flexibility that we talked about because we know where our needs are. If you hook a staffing and scheduling system into a nurse credentialing system and we use, it's called the Works platform, we use this platform to connect the two so we know our supply demand and it's really as simple as basic business principles, but until you straighten that out, you're left probably paying more money than you realize that you're paying and every two weeks when our pay periods end, I think we see the results of that and it is hitting our bottom line in the health system.

(20:58):

So we are looking at that platform to be able to leverage that gives us data in the background and enters AI into the workforce. So launching incentive shifts across is really, really important. We don't want to overpay for a shift, but we do need to pay to get the fill rate we want, so having that technology and AI in the background, we're able to leverage our data to get there on the workforce side.

Lauren (21:24):

Wow, that sounds like really incredible work and it's just so funny to reflect on how far nursing has really come and obviously how much work that you all have put in in terms of the workforce optimization. I remember several years ago I was working on research related to nursing flexibility and realized how many managers are still working in scheduling in Excel and out of their filing cabinets, out of the psychological filing cabinet that is their brain, which are who is on what shift and who needs to be paired with who, et cetera, which is really when you're thinking about the kind of jobs that nurse managers have, managers and directors with how many direct reports they have with how focused they're on care transformation, I think very easy to see why that is no longer sustainable in today's environment. I would just love to let you,

Betty Jo (22:12):

Hey Lauren, giving the nurse managers the data in a way that they can make adjustments is key. And so not just the data sitting out there, but we're providing them information so they can adjust their workforce to the patient needs is so key today.

Lauren (22:28):

Absolutely. So I'd love to, why don't we start at the top of what you mentioned, which are thinking about the layers of the workforce, what did that look like for you in terms of your priorities there and what you really wanted to have aligned before introducing the platform? I think as you so rightly said, knowing that technology can't fix a broken system and certainly that would be potentially even make things worse.

Betty Jo (22:52):

Sure. Well, we look at it in three layers. Our core layer, which is part-time and some of our local RNs that only work on one unit, we looked at offering flexibility in that basic core layer. Those are your FTE benefited retirement type people. Really your bread and butter right of your health system core is still needed in our health systems. If you're going to offer flexibility, you have to understand that core layer first. And so making sure they had enough flexibility and they were able to participate, we can talk about this in a little bit in that technology is key because leaving them out will not leave those nurses satisfied at the end of the day. So that's our core layer at the very top of, we call it like a triangle, is our agency layer and we use a primary MSP, we go through one general company to get our needs met, so our nurse managers aren't having to source contracts, but we have that at the top of our organization.

(23:54):

It's still needed. We've reduced our agency by 62%, but at the end of the day, if we're going to continue to grow, there is still a call for agency and knowing that you have the data to source those where you need it as well as for the most cost effective rates are very, very important as well. And then that middle layer I like to say is newly developed and it's kind of where the magic happens. We've always had float pools, but taking those float pools to the next level when you have a workforce platform that can access that as well in this layer is very important. So we have a regional float pool and that is multiple units in multiple hospitals in our system. We have a local float pool which is only working in one hospital, but multiple units in that hospital. And then we have something called a gig nursing workforce, which is a zero FTE non benefited position, and it has really opened up that flexible layer.

(24:59):

I have about 2,500 gig nurses that work in my system today and they wouldn't be able to do it without a workforce platform. Taking shifts out of the staffing and scheduling system, having that nurse credentialing system and knowing what nurses are available to pick up and the app automatically pushes to 'em, and they are not nurses that normally work in our health system, so they might work at the hospital across the street, but they're giving us their extra time because of the flexibility and the technology in the app. That's a competitive advantage with the technology that allows us to have a higher fill rate than most of the hospitals in our region.

Lauren (25:38):

Yeah, absolutely. So why don't we then layer on the platform on top of those three layers. Maybe if you want to speak to it at a high level or even put yourself in the shoes of a nurse manager or director, someone who works in scheduling to talk about how that would really interact and enable some of the flexibility that you want to offer to these various layers.

Betty Jo (25:59):

Yeah, one of the most important things is we built a labor strategy team at the organization level that took some of that workload off the nurse manager and so about 10 FTEs for all 51 hospitals, and although the managers still do the staffing and scheduling in the system, what's new is any of the holes that are there are filled by this technology and the app lifting certain premium incentive shifts. And so the nurse manager, I am going to take it from their perspective because it's important, the nurse manager no longer has to worry once their schedule's done, the staffing and scheduling team as well as the technology takes over to fill any open shift so they're not calling people on the phone anymore. If somebody calls off at four o'clock in the morning and we put it in the staffing and scheduling system, the automation will take over and launch to any nurse that is credentialed and able to pick up that shift and they pick it up right in their app, they get a little ping and they can decide if they want to pick up the shift.

(27:07):

It also launches the rate, so we're not making decisions at the nurse manager level about rate anymore. That's a behavioral change that I think has far reaching effects than just technology because people are not holding out for incentive shifts anymore because the faster you pick up the shift that's launched to you, the higher the rate you're going to see because as we start to fill our holes, then we launch less incentive shifts. So it's really incentivizing the behavior in the right way and allowing nurses, if they really want flexibility and rate, they want money, they will go to the areas where the money's the highest. If they want to work on certain units, they may accept less of a rate. That's that work-life balance we talked about. Right? They're in control through an app of what they're doing.

Lauren (27:57):

Awesome. That's incredible. I mean I can definitely see how that makes so much sense in terms of your gig work, the float pool, that middle layer that you're talking about that is already based on the premise of flexibility, but it's great to see how it's also benefiting your core staff who are able to take on these incentive shifts as it makes sense for them. But I know who also minimally are not getting 10 emails from their manager that say, Hey, are you sure we definitely have a hole this morning. We really need someone to pick it up.

Betty Jo (28:29):

That's right. That's right. They're no longer dreading. I really don't want to work, but I feel guilty everybody's doing exactly what they want to do, and I will tell you we have a 96% fill rate across the system, so it has driven a tremendous pickup allowing that flexibility and taking really the people out of it and letting the automation take over where it should.

Lauren (28:53):

You already mentioned a couple of the outcomes that this work broadly has been driving technology plus a lot of the strategic work that you've been doing in the workforce. I think you said 62% reduction in agency, which is incredible as well as that 96% fill rate. Is there anything else as you think about where the benefits have been, whether those be hard data, like what you just mentioned or some of the things that you've observed around nurse managers have to imagine that there is a huge relief there in terms of the role. So just curious about what you've seen now that you've had this in place for some time.

Betty Jo (29:25):

Yeah, we do do caregiver engagement surveys and I will tell you we can break it out by type. Our nurse managers are starting to understand the benefits of all of this and are starting to feel the decreased workload. You can see it in their engagement scores. Our quality scores are as good as or better than the nation. And so I was a little bit worried when you introduced a transitory gig type worker because their only requirement is working 12 hours a month. They have to have all the competencies. They're hired as mercy nurses, but their requirements are much less. So we were a little concerned about that. We have not seen any erosion in our quality, and I'll tell you cost is down. So one might say, great, you're reducing costs, but we're able to take that money we're saving and put it back into market adjustments, which is so important for keeping our core with us as well.

(30:23):

So we're balancing each layer according to what has them really in mercy satisfied with the way that they're working. The other thing I'll say is they're allowed to change workforce layers at will as long as they stay within Mercy. That's our primary goal. It's not that they stay in a layer, it's that they're with mercy and they love what they're doing is really the overall outcome here. So that flexibility as well has really helped as people's life change, they can go into a workforce layer that makes sense. Some of the other outcomes, our retention rate, our turnover rate is right around 13% right now, which is great, and our vacancy rate is less than 10%. And so starting to drive where we're heading there, knowing that turnover is not only costly to system, but it's also costly to quality care as well, it can be.

(31:17):

So trying to drive that the other benefit, it is going to be the money side of it, but here's the thing. We did all the things that were right for both our caregivers, our nurses as well as our leaders, and what we're seeing is the money showing up. We didn't go after money. We tried to get the workforce layers correct, put the technology and the data behind it. Within the first year we saved 30.7 million across the system and this past year, another 20 million. And so we continue to see that cost curve bent in the right direction and we can reinvest back into our workforce.

Lauren (31:56):

Absolutely. I mean, wow, 30.7 plus another 20 million on top of it is really an incredible outcome to think through. But I love the point that you're making, which we were talking about earlier in terms of it's really not an either or I think to even think about it in those terms of strategy is going to lead systems down to a place in which they are contemplating rifs or other things that are going to hurt them in the longterm. And so it's just really great to see how this platform, the workforce strategy work that's going into it is getting at cost, but it's also getting at some of the fundamental inflexibilities in the nursing role that are also factoring into nurse engagement. I think one thing that you mentioned that I really don't want to make sure is buried is the impact that you're having in terms of retaining nurses in the profession.

(32:50):

I mean, I'll speak, I come from a long-term nursing family. My mom was an ICU nurse and a renal nurse for a long time before having to leave the profession altogether within 10 or 15 years just because of family concerns. And so it is so great. I mean to see a workforce in which you're going to have those life circumstances, folks are going to be flexing into a different layer that makes sense for them. And then potentially, are we able to join your core nursing workforce when that makes sense for them rather than having to leave forever and then struggling to get back into practice. I think that when you are looking at the shortages that are very top of mind for many folks on this line, especially rural and in certain markets that are really going to struggle, things like this are going to have such an outsized impact in terms of the ability to really retain nurses year over year.

Betty Jo (33:43):

That's right. The other thing is when you introduce, we introduce the Works platform, the beauty of it is Lauren, we not only offer flexibility within our workforce layers, but practice environment. We talked about how the environment's an important strategy. One of the things we're doing in environment is since we have a platform, you can see where you're working, how you're working. A nurse could work one day in my virtual care hospital. They could work a day in ICU and they could work a day in hospital at home or wherever they're credentialed for. They can actually vary their schedule so they're not stuck on one unit for all 36 hours that they're giving us. And so that's a flexibility that most likely they could keep their hand in maybe ICU nursing or maybe they work two shifts a month there and they do the rest wherever else they want to design it. When you have a platform that you can lift out of a staffing and scheduling system and see what's going on and you have the data behind it, you can offer more flexibility that you just can't manually. There's just no way to do it manually.

Lauren (34:46):

Yeah, absolutely. So I would love to wrap the conversation around this work platform and then we can get to more of the innovation brainstorming that I promised a few minutes ago. Curious about from a workforce management perspective is element you've made mention of credentialing. How is that, how have you thought about engaging your workforce differently in terms of structures, professional governance, et cetera, given that this is I think an exciting and great change for your workforce, but certainly a change nevertheless?

Betty Jo (35:18):

Sure. So we do have professional practice teams in Mercy. We have a shared governance model in that way. They were actually engaged from the start. So everything that we're talking about here today was not designed by nurse leaders, but it was designed at the bedside by nurses that were looking for that flexibility and we're looking for great ideas for them to keep going. We don't want to stop here. We want to keep innovating from their perspective. And so our shared governance, our professional practice teams have a lot of say in this and they actually participate in, we set a rate card every year for our premium labor. They participate in what those rates would be so they understand when they see data, they're seeing the data and the outcomes from this workforce platform. They understand where we're trying to go to provide better patient care and they're leaning in and making decisions with us. So that's the other beauty. And the reason I think we got this right was because of them, Laura, and it wasn't, hey, we were just lucky and released it and everybody loved it. We innovated and did things with them before we released this across our whole organization.

Lauren (36:26):

Absolutely. So I also wanted to brainstorm with you and look into the crystal ball 10 years ago. As I've been in conversations with folks around care transformation, what strikes me is not only how the strategies that folks are doing right now are helping with some of the medium term challenges that health systems are looking at, labor costs, access shortages, we talked about a lot of those. They're also really carving the next generation of nursing practice. So some health systems that I'm working with very focused on standardization, all systems and all sites are going to be practicing in the same ways. Some folks have said, you know what? It's our choice as a system where we are going to hold the same bar in terms of quality, in terms of practice and engagement, but ultimately we're going to allow folks more flexibility site by site to be able to practice in the way that looks most for them. So I think no right or wrong answers just to say that the choices that are being made now are going to have a huge impact on the next generation. And so we're looking into your crystal ball, whether that be for Mercy specifically or nursing more broadly, where do you want to see nursing be at five, 10 years from now?

Betty Jo (37:37):

I'm going to give you the base for my thoughts first. Number one, evidence-based practice is showing us probably where we need to go. It's showing us what we've designed is going in the right direction, but we can't leave out the evidence here, the evidence-based practice models that we need to look at. And so evidence combined with, and I'm going to throw this out here, the nursing process, as we're in nursing school, we are taught in nursing process. When you look at what nurses are doing all day long, they are designing around the nursing process. Now, that nursing process was designed in 1958 before we had any of the technology. EHRs were not a thing and it worked fantastically. The nursing process today, if you take a look at it, what we've done in the last 15 years is maybe even 20. We have automated an EHR.

(38:33):

We've gone from paper to an EHR. We've put systems in place that nurses have to schedule in. We've introduced some advanced thinking and IV pumps and things like that. So what we've really done is introduced care variation on top of the nursing process, and we've never gone back into workflows to say, how do we design the technology that's so needed, the innovative thinking into that nursing process and clean up those workflows. So that's the basis of the thinking, assessment, diagnosis, planning, intervention and evaluation all day long with all this technology and on top of it creates this cognitive workload burden that we talked about. So it's so interesting when you take a look at that, what can happen to you if you're not careful, and I think that's what got us to where we are today. So we can get back out of that by taking a look at the evidence and saying, where do we redesign that nursing process with the technology that we have?

(39:31):

And AI is giving us a huge advantage at this point so we can serve up information that nurses are searching for out of an EHR to make critical decisions. They're spending, they a large majority of their shift trying to comprehend data and things out of the hr, which is why we introduced virtual nursing if you think about it. But now enter in ai. We can use virtual nursing in a different way, and you talked about it in the beginning, which was beautiful. But today, nurses still need, if you're going to reduce care variation, they're going to be able to use, they're going to have to be able to use mobile devices. We've got to get them out of a computer, get them mobile and get it digestible in a mobile format that they can both extract information as well as put information back into the EHR.

(40:21):

So looking at how we serve up information at the right time is going to be completely key to redesigning this nursing process. So that's where my big bet is in the next five years is redesigning those workflows with the technology that we have, and I will say standardizing the things. We can standardize one single IV pump across the whole system. One instance of an EHR, so nurses that are moving around for flexibility know what to expect when they hit different units, going to be key to workload, right? As well as our novice nurses who are entering practice. If they can get information they need right at their fingertips, for example, central line dressing changes, they shouldn't have to go to a policy to get it. They should be able to bring up the policy by voice activation and they should be able to watch a video because guess what? Our younger digitally savvy people will want that availability. So even as we're working in our work environments, taking a look at what our five generations that are in the workforce today are going to need to be successful is going to be key. Again, you'll notice the theme from their perspective.

Lauren (41:32):

Yeah, absolutely. I really love that you brought up care standardization for all the reasons that you mentioned because A, there's new technologies at hand that are both going to enhance it standardization, but are also just going to be less difficult and are going to be less of a burden on the nurse. So the introduction of a, I shouldn't say introduction, A lot of the attention and effort that is being put into AI right now provides that opportunity, but also B, standardization is a key enabler of the kind of flexibility that you're putting into practice. I think a lot of folks had this experience with virtual nursing where they wanted to have their virtual nurses flex only to realize that every single hospital had a different discharge procedure. And so it'd be really hard to teach someone and to have them be able to think through that way, even if that was difficult to flex staff and to think about care differently when that is going to be a huge barrier to doing all and to leveraging the scale that many folks are having within their systems.

Betty Jo (42:27):

That's great.

Lauren (42:28):

I want to wrap our conversation and then we will pivot to that Q&A with the folks that we have on the line by talking a little bit about failure, which I know is something that when you have the outcomes that you've had, I think that's easy to feel like it was a clear skies only smooth sailing for Betty Jo and team, no problems whatsoever on the horizon. And so want to normalize that sense of even as you look to accomplish big profession changing goals like you and your team are doing right now, there can be a lot of speed bumps along the way. Would you mind sharing an instance, a failure story with the group on the line in service of normalizing some of those feed bumps and the efforts to a lot of the great work that I know is happening both at Mercy and with some of the other systems I see,

Betty Jo (43:20):

I'm sure everybody's doing great work. I'm going to give you two quick examples. One of them is in workforce and it highlights really why technology and the partner that you choose is important. It took us, we were the first truly AI driven system for workforce. When we came down off the pandemic, we really worked hard with our partners. I'm just going to say Trusted Health. They were our partners and the beauty was we were designing as we were flying the plane at the same time, because nobody had done AI in the background to lift incentive rates. We must have literally failed 10 times together though we had partners until we got the rates right, and the algorithm in the background, forget AI is a large language model. It needs data to learn and be smart. Well, we didn't have any data, and so we started with assumptions.

(44:18):

We tried to predict and we were able gather to see the data, and we made, I'll bet within the first year, 20 changes to our modeling in the background for where we wanted to. And we finally settled on something. It took us about a year though to get there. So there was some struggle, but here's the beauty. Now that we have data sets across the country, we can combine and think about this easier. So anybody that maybe waited to lift this and is thinking about lifting it, great news, you're going to jump in much faster than we did. We had to learn. The second thing is, and I want to highlight this because everybody's a little bit fearful of AI today with good reason, and I want to say that it is responsible AI lifted in the right spots, but we started on one unit in one of my hospitals and did an ED to inpatient handoff with an AI generated report into an SA format.

(45:13):

Now, when we first started this, we used one unit as our test of change, and we didn't realize because we had never done this before, that the physician and the emergency department in order to lift some of the data out of there, had to sign off after they wrote the discharge order or after they wrote the inpatient order, they had to sign off before the AI could go in and pick up some of the information there. And we were missing some pieces of information. But again, that's why we kept it to a very confined spot, and you'll hear an AI talking about hallucinations. That's exactly what was going on because it couldn't source the data until the physician signed off. So we had to change some practice there, but we learned together and the nurses and my nursing informatics team right there at the elbow helping them shout out to any nurse informatics on the line, love you are our way to the future. So at the end of the day, they were at the front lines really helping, and then we were able to go to whole hospital and then we launched ministry wide. So being careful as you're doing it, you are going to fail, but you're probably going to fail if you don't start doing something anyway, so

Lauren (46:21):

Yeah, absolutely. Well, we really appreciate your vulnerability and just to hear even more about the texture of your journey and what that experience was like. So as promised, I wanted to save a few minutes at the end as we get up on time here for direct Q&A from the audience, I see a lot of folks around the line have videos on. If you want to, feel free to unmute yourself and ask your question live. Feel free to do that now. Otherwise, I'm going to go in order of the chat and a couple of questions that were emailed to me in advance. So don't hesitate to unmute yourself and go ahead and ask if you have any questions in relation to anything that we talked about.

I do want to start with Donna's question in the chat. Hello, Donna. Hopefully you're not sick of me after seeing me twice in two weeks. A question for Betty Jo, do you have any campuses with RN union representation, and if so, how does it work to float non-union nurses into their campus or vice versa?

Betty Jo (47:18):

Okay, so the great thing is we do not have any unions, but I can tell you, I get this question a lot and I've thought through it just a little bit. As you're looking at your shared governance or professional practice teams, one of the things that is really important is that you have an AI governance team of frontline nurses that are taking a look at some of these things, and for workforce with the AI in it, they designed this system and they asked for the flexibility. So if you had a union, it doesn't come from management, it comes from the front lines. And that's been successful in a couple places is that it is coming from the front lines, and we still follow the pecking order of how we cancel people, how we bring people in. It's all building into the technology. So you could still design around the union requirements, but I would definitely make sure if you have a union that you have some frontline representation on that.

Lauren (48:16):

Absolutely. I also had a couple of questions submitted to me. Again, if this is triggering new questions for you, feel free to keep those going in the chat. But another question for you, how does your AI governance structure look as Mercy is developing AI models, whether they be part of your work with Works and Trusted Health, or for the other initiatives that you have going on?

Betty Jo (48:40):

Well, first of all, this is far bigger than just nursing as you can probably imagine. We belong to professional organizations that govern ai, and in my office of transformation underneath my CIO, we have a full-blown structure that not only just for nursing, but we're governing other AI projects, and it goes through that full representation. My nursing informatics leader sits on that governance structure and brings anything forward, and our entire roadmap runs through that overall governance structure, and then we put project planning to it to make sure that even as we're planning these things, that we have technology and AI representation into the building and thinking behind it. So it is a larger structure that we fold into.

Lauren (49:30):

Yeah, absolutely. One more, probably another one that you've gotten and many questions. What did it look like to fund these efforts, especially when you are in the testing phase? How did you think about approaching that as an executive?

Betty Jo (49:45):

Yes. So a business case, just like we did for any other project before AI was on the market, we had to put together a proposal that had the return on value. It isn't always money, but there is value or we wouldn't be doing it. And it also sits strategically into our Strategy 2030 plan and our Senior Leadership Playbook. So I position those efforts into the organization and make sure that we have signup. The other thing is in our organization, nursing has been thinking about this for a while. So we had our roadmap built out pretty quickly, and we're able to take it to the governance team fairly quickly. So it has to be approved at the senior level, which I sit on a business case, and then it has to go to the AI governance team to make sure that we can accomplish it. If all those three things happen, we can either get partnership support like we did with Trusted Health, or if it's another partner, we partner with Microsoft as well for some of our workflow things, it gets sign off in those areas and the business case is carried on through.

Lauren (50:52):

Thank you so much. I think that brings us until the end of questions, speak now or forever hold your peace for everyone on the line. So thank you so much, Betty Jo for sharing your wisdom for us today. It's really such an honor to be able to talk about your workforce work, your work in terms of ai, but also just to hear your thoughts more broadly in terms of the future of the nursing profession. So really appreciate your time, your insight, and everything that you're doing at Mercy to really drive toward that next generation of care delivery.

Betty Jo (51:23):

Thank you. It was my pleasure.

Lauren (51:25):

Awesome, and thank you to everyone on the line. You'll probably see a quick survey pop up. We greatly appreciate your feedback, so try to take that in the next couple of minutes if you have the opportunity. Otherwise, let our team know if there's anything else that we can do for you and have a great rest of your afternoon.

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Related: 

• How Mercy created a more flexible, efficient clinical workforce leveraging Works
• A CNE’s Perspective: How to Leverage AI to Transform Nurse Workforce Management
• Workforce Transformation: An Ecosystem of Flexibility