Episode 1: The Future of Travel Nursing

[00:00:00] Casey Buckingham: If I had my crystal ball, I would say there is not much future for travel nursing at Benefis, just because of our culture. However, I think for healthcare, it's a great tool in your toolkit that you can utilize in those times of need and just evaluating when the responsible time is to utilize it and when not to. Part of the reason we can also be so creative and nimble with our practices is we're nonunion. I think that there are some organizations that have different limitations too and it's understandable. I also think it's a way of life for certain nurses. I hope for people who like that sense of adventure and that model that it's available, even if it's not something that we're going to utilize within our walls. [00:01:19] Bianca A. Briola: Hello, and welcome to the Alvarez & Marsal: Healthcare Industry Group Human Capital and Workforce Management podcast. In this podcast series, we discussed the most pressing workforce issues facing healthcare leaders. I'm Bianca Briola, leader of the Human Capital and Workforce Management Practice. I have to say, I've really been looking forward to this discussion, mostly because these are two of my favorite hospital administrators and leaders. Also, they have a very interesting story and I can't wait for them to share their journey, their information, their organization, with our listeners. We're joined by two leaders from Benefis Health System in Great falls, Montana. Casey Buckingham, senior vice president of human resources and Rayn Ginnaty, chief nursing officer and hospital chief operating officer. Casey and Rayn, we're so excited to have you as our guest, to have you offer your perspective on the future of travel nursing. Welcome to the show. [00:02:21] Casey: Thank you for having us. [00:02:23] Bianca: Well, let's get started. As I mentioned, I'm really excited to chat with you both about Benefis. I've had the opportunity to work with both of you at Benefis several times, and I've always been struck by how unusual an organization Benefis is. Casey, can you tell us a little bit about Benefis and your role there? [00:02:45] Casey: Sure. Benefis Health System, we are a system that has a continuum of different care, not just a hospital, but we also have a cancer center. We have a robust heart program, long-term care services, as well as a couple other areas in outpatient services. We're really the hub for medical care in Central Montana. We're located in Great Falls. Our employee population is about 3,400 and 900 of those are nurses. A couple of things that I think makes Benefis really unique is we are a not-for-profit. We're an independent organization. From a workforce standpoint, we have a no layoff policy, which was definitely put to task during the beginning of COVID. I think another thing that makes us unique since we're talking about traveling nursing is we did not have travelers in our organization after 2007 until recently. I've been with the organization since August of 2007. When I interviewed was when we exited our last travelers that we had in the organization that were in our long-term care facility. We've been traveler-free up until the last couple of years with the pandemic. I think that makes us very unique from an employment model. That's definitely our preference. We've also shifted our providers to more of an employed model and have over 300 providers that are employed with us here at Benefis. [00:04:24] Bianca: Oh, my goodness. Three very interesting things that I'd like for us to talk about. Let's make sure we touch upon all three items that you really pointed out as very unique attributes of your workforce model. No travelers until recently, no layoff policy, and then moving providers to an employment model. Thank you for that introduction. Rayn, you have a very interesting role as chief nursing officer and a chief operating officer. I can only imagine that the past few years has been incredibly challenging for someone in your role just based off of scope. What has the past few years looked like for you and Benefis? What did the pandemic look like? [00:05:15] Rayn Ginnaty: Thanks, Bianca. Certainly, as I think about the healthcare profession, I don't think anyone ever saw or thought that they would experience a pandemic during their career. However, that being said, I think as you think about caregivers and the role that we all have in healthcare, I think the biggest impact was just the length of time that this pandemic has gone on. Just the very difficult challenges early on with, what did care look like for these patients? Then how are we ensuring that when those that were originally diagnosed with COVID were able to connect with loved ones when that couldn't be in the physical presence. All of those challenges that came with all of the death that we were seeing initially with that first wave and just the toll overall that that took on our caregivers throughout the nation and certainly here in Montana as well. As it relates specifically to your topic today I think the greatest impact that we saw was just this interesting-- just to boil it down to its simplest terms, you had people that rose to the occasion and wanted to be a part of that each and every day even over the course of the last two years. Then you had those that decided maybe nursing wasn't for them and this was not the vision that they had in their minds when they thought about being a nurse. We saw in the workforce a lot of people reducing FTE, stepping out of the workplace, maybe even retiring early over the course of time. Then in addition to that, as the demand for patient care has increased in the acute care settings, we certainly then had that impact of not enough nurses to take care of the volumes that we were seeing. With that, that led us to really having a very stressed, overworked, burnt out workforce just in general. When you add all of those things together, it has been an ongoing challenge that I think while the pandemic may be subsiding, I think we're truly not even to the peak of the impact that we'll see on our caregivers. [00:07:46] Bianca: Oh, okay. That's really interesting. I'm surprised that you said that and also troubled and wonder if the activity that we're seeing with resignation and reshuffling, if this is not only just the beginning, but if we're going to experience a protracted and long-term reshuffling of the deck. That's very fascinating. I'd like to learn a little bit more about what you said. You shared with me two different factors that were significant pressures. One, those leaving for various reasons that you mentioned and then a surge in volume, of course. Casey mentioned at the beginning of our conversation that up until the pandemic, you did not use any travelers. Can you tell me about the environment that Benefis was in that allowed you to operate without travelers? That's such an enviable position for many organizations that would love to be without the use of the most expensive labor type. [00:08:57] Rayn: I think what I would say is we have just a culture of creativity here. First of all, we are Medicare break even, which not many hospitals in the nation can say that. With that, becomes our challenge. You have to marry finance and quality of care together, which is often something that as a nurse or as clinicians, we don't learn about in school but there is a fine balance there and those have to go hand in hand. When you think about that, I think it's important that you're always mindful. What we've done internally is a lot of education and have had a lot of dialogues with our bedside staff on the importance of the financial and the quality impact in healthcare. With that, then becomes really the conversation of, how do we make sure that we are taking really good care of our patients in our community and in our region? How do we make sure we're taking really good care of the nurses who take care of those patients? For us, when you think about some of the high cost contracts that are associated with travelers, it became very easy for us to say, "We really want to make sure that we are recognizing the contributions of those individuals that are living in our community and dedicated to Benefis Health System." We made it a priority to not have travelers so that we could look at creative ways, not only to ensure that we are keeping those individuals in our health system working, but that we're rewarding them monetarily for their efforts and really focusing that internally. When you think about some of the staffing challenges that then come with that, we have done multiple things like cross training across our health system. Casey mentioned that earlier. We are very lucky that I have an outpatient clinical practice right across the street. Those nurses that work over there are cross chained in the hospital and vice versa. I have nurses that can go over and help in the outpatient setting, although that doesn't happen as often. Those nurses from outpatient then when we see increases in census are able to come over and help resource at the bedside with nurses that are typically in those roles and competent to really help out to take care of the patients at the time. That is just one example of a way that we have just really used creative ways to redeploy, if you will, nurses across the health system. Some of those may be in office settings to take care of patients when we need them. [00:11:46] Bianca: That is definitely one of the strategies that other organizations use during the pandemic. Up until that time, they really didn't explore more of that job sharing. That's probably not the right term. Casey, can you tell us a little bit more about the organization? How many staff members you employ and then also your market, what are some of the other major employers in the area? That's more of my own curiosity to help set some context. [00:12:23] Casey: Sure. You bet, we have around 3,400 employees and 900 of them hold nursing license. We also, Bianca, are really careful when we're creating new positions, really looking at, does it require a nursing license or can it be other ancillary service criteria, just because we want to make sure we're not taking our nurses from the bedside or presenting that as the only option. That's another way that we really look at that. We do have a for-profit smaller organization that's local here, and then we have an air force base, which that doesn't make a big difference to anybody unless you're in a town that has a military presence. Because of that, we actually get some really great experienced employees in a variety of different fields that come work for our organization. Great Falls is normally about a five-year deployment for people. We do have the benefit of having the air force base, which also brings some diversity to our organization, which is another, a really great thing for us. [00:13:35] Bianca: Agreed. Thank you for answering that question. I've been to Great Falls. It's a wonderful town. I can see why you attract individuals to your organization. It is a beautiful location. Let's chat a little bit more about the topic related to the future of travel nursing. I want to learn, what happened? You had this practice. It's not a policy, but a practice to not utilize travelers or contingent workforce, unless absolutely necessary. That afforded you the opportunity to be traveless for quite some time, but then the pandemic happened. Can you tell us about how your practice around contingent workforce change, Casey? You don't have to limit it necessarily to nursing. If you use other traveler or contingent labor, I'd love to hear about it. [00:14:28] Casey: Perfect. Well, I will tell you that during the pandemic, it snuck up on us and it snuck up on us because our state paid for it on our behalf. We had some state funding. We had FEMA, we had National Guard and we had contingent workers that were coming in and helping us and we really appreciated it. We weren't paying the bill and we weren't seeing the bill. That's why I would say, they came in disguise at first. We knew they were coming and we definitely needed the help and we had increased census. It was great to be onboarding fresh faces and people that were really coming in and helping our tired and weary workforce. Really, when we first started having contingent workers, we weren't footing the cost of it, which was very nice. However, we knew that wasn't going to last forever and those funds were going to disappear very quickly. We just made sure we had a really good strategy around what areas we were going to have traveling nurses. We also have respiratory therapists and we've had a couple other areas, even in our critical access hospital as well. Just keeping a very close eye on how many and extending contracts, what that was going to look like. When we did start getting, we converted the state contracts over to ours and started paying for those, but just being very conscientious on how many and for how long that we had. For contingent workers and the rest of the organization, we really don't have traveling contracts. We do have some agency personnel that work for organizations that we outsource that work inside of our facility. We still can really consider them more of an employed model because it's the same people every day, not a revolving door of people coming and going or different faces. Really, during the pandemic has been the only time we've really had any contingent workers at all in our organization besides who we have a couple contracts with. [00:16:42] Bianca: What about now, Casey, will Benefis be using contingent workforce, travel nurses moving forward? Do you still have folks in-house that are considered contingent or travelers and what specialties, what shifts, what does that look like? [00:17:01] Casey: Right now, we have 12. We've really reduced the number. I think at our peak, we maybe had between 60 and 70 from a head count but have really tried to reduce those as our census is loosening up. As our hiring practices are on the right track, our plan really is to not have any travelers by the end of the summer, even midsummer is what our goal is. We're really moving back to our philosophy that works so well for us is we would rather pay that extra money to the people that are committed to the organization and our patients and taking care of their neighbors than pay a premium for external help. That strategy has worked for us. It's really what our employees are used to and like as well because I know during this time, we've had a lot of people who did not like working next to somebody, even though they were there to help, that were getting the premium pay offering that they were. Really, that's what our strategy is. Respiratory therapy is an area we've needed additional help in, CNAs in our critical access, and some cath lab personnel as well are the areas outside of just the acute nursing that we've needed assistance. [00:18:21] Bianca: Usual suspects, we hear about those roles across the nation. That is one area you're not unique, but still very interesting. This is a question for you, Casey, as well. There's some talk, we hear about it in the news, and this might just be more hype than not and I want to get your take on it that there might be some federal or state-level legislation to regulate or cap travel nursing. The intention is to limit cost and address some of the things that you're talking about. Do you think that this will come to fruition? [00:19:01] Casey: I can only speculate, my thinking is it will not because organizations and travel companies still have to-- it's a supply and demand setting. It's really no different than some other things like gas prices. I don't see price-fixing from a compensation standpoint happening just because there's areas travel nurses would like to go that probably just with supply and demand, even when the market's more steady with nursing license and not having as many shortages, I just don't see that happening. It's interesting to watch. I think the most important thing for us is that the misinformation is that all organizations or nursing wages are being capped and not just with travel companies. That's part of, I think, just misinformation and an understanding on employees parts where they think that we're actually capping those wages on an employment model, which were not. It's interesting to hear the buzz out there and it's then interesting to hear the rumors associated with the buzz. [00:20:13] Bianca: You're using the term misinformation and that resonates with me. We had a conversation with an executive of a travel nursing agency and he spoke to misinformation as well, and very similar in concept to what you just shared, that there's this misconception that travel agencies and organizations are driving up wages. He educated us a little bit about the supply and demand and how the nursing travelers, they really can help support those wages and what they're asking for as well as where they're willing to go. There's a lot more that the public doesn't necessarily see and you as a consumer of travel nurses, you also can educate us a little bit. That's very helpful. Rayn, big question for you. Casey had mentioned that there's this investment that Benefis is making in existing staff. Keep them happy so that they don't leave or that they feel engaged, that they're more willing to take part in the journey of the organization. You would rather invest in that staff than, for example, bring in contingent workforce. She also mentioned that maybe some of the staff wasn't really excited about working side by side next to contingent laborers. Can you assess that out a little bit, talk to us a little bit about what you heard from your nursing staff and other staff about having contingent workforce and travelers at Benefis? [00:21:51] Rayn: I think certainly at the beginning of the pandemic, when we really, as Casey talked about when the help from the state was exiting the organization, we knew that we needed to reach out. For the first time in my 20 year career here, I experienced that first reach out to a traveling company from a contract perspective. As we did that, certainly for eight months to a year, it was needed. I think our workforce overall was extremely appreciative. Over time, as I think we got, I don't know if you could ever get used to the pandemic, but as we've learned more and we understood how to care for these patients, and we were able to really develop strong plans of care and standards of care around COVID, that is when I think the discussion shifted a little bit. As we saw maybe some of our volumes still very high, but not stabilize a little bit, conversation shifted more to, "Gosh, I'm still having to work-- as an employee of Benefis, I'm still having to work more. What is my benefit? What is out there for me?" Those are very fair questions. The minute we start to hear those kinds of things, that is one of the things I think is unique, Casey, and I have a very strong relationship as it relates to employee face time and really getting their feedback. We immediately started doing focus groups with our employees to talk about-- really what it was about was retention, at the end of the day. What are we doing to continue not only to help staff and hire because those things are important. You needed the travelers, you needed to continue to recruit, but what are you doing to take care of me, your employee that is dedicated and a part of your family. Those conversations led us down a path if you will, or an action plan of things that internally we looked at. Always we're looking at our market based pay and things like that, but are shift differentials strong enough, weekend pay, some of those pay incentives that you have that are very standard across the organization. I think the one that really ended up coming to fruition for us as it relates directly to pay is a concept of triple time. Essentially, the idea was as employees internally are picking up an extra shift, each pay period, if by their choice or extra shifts, plural, because some do that first shift is paid out to them at a triple time wage. That was very much a grassroots suggestion by our employees that we were able to implement that made them feel heard, and made them feel like they were appreciated for the extra work that they're doing as it relates to that compensation comparison to travelers. [00:24:58] Bianca: I have questions about triple time because this is interesting. I haven't heard anyone use the triple time term yet. Is it still in effect? [00:25:08] Rayn: Yes. [00:25:10] Bianca: Is it the intention that this will be the policy or program moving forward or do you have plans of sunsetting eventually? [00:25:20] Rayn: That's a great question because that will take you right back to where I started when it's a balance between our clinical team and quality and outcomes and finance. As we developed that plan, we do so in partnership with finance. At the time when it was developed, there were three or four indicators, if you will, that have to be met when that would then sunset. Those indicators kind of very broadly are back to a budgeted census, not seeing the extreme volumes that we're seeing today. We all have a budgeted average daily census or an area where we'd like to see our staffing on average, when our units are back to those budgeted average numbers, then the triple time would sunset. Those are just a couple of the metrics, if you will, that we put in place when this was rolled out to determine when it would in fact be sunsetted. [00:26:17] Bianca: You're speaking in a way that reminds me why your organization is one of my favorites. Is that discipline and rigor and really using data to make operational decisions. This is a perfect, perfect example. Very, very impressive and one that we would recommend is having these clear timelines and tollgates to follow in order to sunset a policy. I guess my question for you is, was this communicated to the staff more broadly? Do they know what the future of that process and program will be? [00:27:04] Rayn: It was and when we did that, we boldly communicated it to all employees, those impacted and not impacted for a number of reasons. One, we have also a culture of transparency. Two, as a health system, we survive because we have a great team and it's important that every employee in our health system knows what we're doing to take care of our employees. In that communication, we did share with them what those metrics were that would allow us then to sunset this practice. [00:27:49] Bianca: That's so impressive. I've always really admired the approach that your leadership team has taken for this type of work. Well done. I have a question for both of you now, I'd like to hear from both of you and maybe we start with you, Casey. Get out your crystal ball, the question of the hour, what I've been asking all of the leaders and experts for this particular episode is, what does the future of travel nursing look like? What do you think? [00:28:23] Casey: Well, here at Benefis, if I had my crystal ball, I would say there is not much future for travel nursing at Benefis just because of our culture. However, I think for healthcare, it's a great tool in your toolkit that you can utilize in those times of need and just evaluating when the responsible time is to utilize it and when not to. Part of the reason we can also be so creative and nimble with our practices is we're nonunion. I think that there's some organizations that have different limitations too and it's understandable. I also think it's a way of life for certain nurses and I hope for people who like that sense of adventure and that model that it's available even if it's not something that we're going to utilize within our walls. That's my crystal ball. I'm hoping that this might be the one and only time I've had an experience with travel companies. We've had a really great partnership with the group that we're working with. I think we had a positive experience even though it's not where we want to be from a model standpoint but I do, I think there is a future and I think it's a good tool for people who need resources, especially when there's workforce shortage. [00:29:49] Bianca: Rayn, how about you, from your perspective being boots on the ground and operations for nursing, what does the future of travel nursing look like for you? What do you think is going to the industry? [00:30:02] Rayn: I think, I completely agree with what Casey has said. I would just offer one perspective that I wish I could maybe look at a little diff-- if I'd known what I know now that maybe I would've changed. That is really about just what happened, I think what I saw across our PPS hospitals in the state of Montana. If I could go back at the beginning, I wish we would've, if you will, locked arms because what we ended up doing, I think is even internally driving some of our own costs up across the state. We would have nurses leave, say, organization A in the state and travel two hours to organization B in the state for a much higher wage. I think that if we could have addressed that maybe as a group, as a state effort, I think it would've helped us all a little bit differently in that we wouldn't have had that loss of people internally across our different organizations to go and travel. That is obviously a crystal ball look back. I think that is one of my lessons learned, if you will, in regards to maybe what I would've done different. [00:31:25] Bianca: That's very interesting. Some states were more organized than others, but I think that unanimously, folks would agree that there was a flurry of unnecessary competition created, particularly in the beginning of the pandemic that really caused both supply issues and generated increased costs that now we are trying very hard to pull back, but it's been challenging. Once you go so far, it's difficult to go back. Well, we've concluded our initial questions about this topic. I do want to ask you about one more thing. Casey, in the beginning of our discussion, you mentioned you're a no-layoff policy, and this is very unusual. You don't see this often in a hospital or a health system, not because of a lack of interest or lack of desire. I think that there's a lack of commitment that they'll be able to fulfill that policy. I'd love to understand from your perspective, what generated, what brought you to the point of creating this policy? How have you been able to maintain this policy for so long? [00:32:36] Casey: Perfect. I'd love to talk about it. Our policy was initiated in 2002. What makes that a milestone event, it's when our CEO, John Goodnow came to Benefis and created it to make sure that employees knew that we were committed to them because they were committed to us. I started in 2007 and it definitely was a great recruitment tool for me as an HR professional because I hadn't ever heard of them. I hadn't ever seen one and I hadn't known an organization who had them in place. It is very unique in healthcare. I think we've had two waves of times where it's been put to test a little bit and especially during the pandemic. A great example is during the pandemic, when other organizations were doing layoffs or furloughs, we didn't. We did have a short period of time where we shut down different services and those employees were redeployed to other areas in our organization. Their pay was kept full but they maybe were doing something very different. We may have had physical therapists that were working in our Pop-up Child Care Center for employees that we had. Their pay and benefits remain all in place. The no-layoff policy is really what it is. It's our commitment to employees that they have security in their job. Part of the reason it was initiated too is because our CEO and I agree with the statement that if you have layoffs, it's a failure of leadership. It's not a failure of your employees. Really living up to that promise and that commitment. A lot of years, it's very easy because we are not looking at services that are struggling but during the pandemic, we really utilized it heavily. I was very proud of being able to make sure that there were no lost wages, there were no layoffs. We really supported our employees and their families during a really tough time when other organizations were not doing the same. [00:34:42] Bianca: Agreed. Well, once again, you prove that Benefis is a very unusual place. I don't mean unusual in a bad way. You're in a very unique position with very unique leadership that has a very unique philosophy. I think that if anything, great case study something to provoke thought and certainly a great networking opportunity. If other organizations are interested in learning about the Benefis secret sauce this is, you're giving us some insight into what's going on there. Thank you both for being so honest with us and offering your perspective. I really appreciate your time.