Feature | Cardiovascular Business | May 03, 2019 | Ruben Filimonczuk, RCES, AS-PMD

Taking The Heart Team Staffing Business Seriously

Hiring and retention of good cath lab staff is essential, but turnover remains high

Cath lab staff working as a team to prepare for a procedure at Presbyterian Medical Center Cardiac Cath Lab, Charlotte N.C. Pictured are Barry Horsey RCIS, Emily Luna RN, RCIS, Adam Martin RCIS, Caleadia Jessup RN.

Cath lab staff working as a team to prepare for a procedure at Presbyterian Medical Center Cardiac Cath Lab, Charlotte N.C. Pictured are Barry Horsey RCIS, Emily Luna, RN, RCIS, Adam Martin, RCIS, Caleadia Jessup, RN.

One of the most promising areas for innovation in healthcare is to be found in the workforce – both in hiring and retention. But for years, healthcare has endured high turnover, and the trend seems to be accelerating. According to a study by National Healthcare Retention and RN Staffing Report,[1] the average hospital turnover rate in 2017 was 18.2 percent, the highest recorded turnover in the industry for almost a decade. Since 2013, the average hospital turned over 85.2 percent of its workforce.
Market analysts say that healthcare’s turnover is second worst after hospitality.
Nurses and technologists whose work directly impacts patient care, patient safety and patient satisfaction appear to jump ship far too often. It was reported that the turnover rate for nurses in 2016 was 14.6 percent, according to a survey by NSI Nursing Solutions.[1] The cost of turnover will have a profound impact on already diminishing hospital margins and desperately needs to be managed. Industry experts estimate the average cost of turnover across all occupations in the healthcare industry is around $60,000, although specific positions have a varying impact on a hospital’s bottom line.
A study in the Journal of Nursing Administration found that the cost for a nurse or technologist can be as high as $97,216, climbing even to $104,440 if we include pre-hire recruitment expenses, unstaffed beds, overtime, losses in productivity and, needless to mention, the utilization of “travel” nurses/technologists, which can be quite costly.[2] 
Patterns in Nurse Turnover
A report put out by the National Healthcare Retention and RN Staffing Report in November of 2018 points out several patterns of turnover.[1] First, we can look at these patterns by positions deemed applicable to the cath lab environment. Registered nurses averaged a 16.8 percent turnover, with bedside nurses coming in a little lower on the scale, as opposed to emergency room nurses and surgical nurses, averaging the highest. 
Radiologic technologists, along with invasive cardiovascular technologists, averaged roughly an 11 percent turnover. 
Looking at these numbers by region and facilities shows that current turnover rate for acute care hospitals is roughly at about 18 percent, with government-owned facilities experiencing the highest rates of total turnover, climbing to 20 percent.
The south central region of the U.S. (Ark., Ariz., Colo., La., N.M., Okla., Texas and Utah) has the highest regional turnover at 19.1 percent. The north central region of the U.S. (Iowa, Idaho, Ill., Ind., Kan., Mich., Minn., Mo. and Mont.) has a regional turnover at 16.8 percent. The southeast region (Ala., Fla., Ga., Ky., Miss., N.C., S.C., Tenn., Va. and W.Va.) comes in at 18.4 percent. The northeast region (Conn., D.C., Del., Mass., Md., Maine, N.H., N.J., N.Y., Pa., R.I. and Vt.) has total turnover numbers showing 17.8 percent. The west region (Alaska, Calif., Hawaii, Nev., Ore. and Wash.) has the lowest turnover rate at 16.5 percent.
We could look at turnover percentages according to other healthcare positions, tenure, facility sizes, ownership (profit or non-profit), etc., but for the purposes of this article, the data provided above will suffice.
Top 10 Reasons for Nurses Leaving Jobs
Voluntary terminations accounted for 92 percent of all hospital separations. To further understand turnover, a recent survey asked participants to select three reasons from a list of various possibilities as to why individuals would resign. Personal reasons (caring for a child/parent, marriage and disability) came in first, relocation placed second on the list, and retirement moved to third place. As the population ages, expect this to remain a driving force for future separations. Rounding out the top 10 reasons, but not in any particular order, are career advancement, salary, workload/staffing ratios, scheduling, education, immediate manager, and commute/location.
Patient Populations Continue to Grow, Raising Demand for More Healthcare Workers
Simultaneously, the healthcare industry is growing. Roughly 40 percent of hospitals surveyed in the National Healthcare Retention and RN Staffing Report had an increase in their labor force throughout 2018. With more people suffering from heart disease than ever before and an aging population, cardiovascular technologist jobs are abundant, with a projected job growth of 22 percent from 2014-2024, according to the Bureau of Labor and Statistics (BLS).[3] The BLS also projected a 12.3 percent employment growth for radiologic technologists between 2016 and 2026, and within that period, an estimated 25,300 jobs should open up. 
In conjunction, employment of registered nurses is projected to grow 15 percent between the years from 2016 to 2026, much faster than the average for all occupations other than cardiovascular technologists. Here are three of the major cath lab industry roles where employment growth is on the rise, and yet are major contributors to high turnover.
Cardiovascular Services Market is Becoming Very Competitive
The cardiovascular services market is becoming very competitive, presenting job opportunities within this specialty at numerous programs opening up all across the nation. The blend of high turnover and growth is creating staffing gaps nationally that have an impact on a hospital’s bottom line, which can be very costly. Based on the current scenario, staff retention should be considered of major importance to all healthcare organizations. The implementation of employment policies that focus on maintaining the workforce currently in place can bring greater staff retention and stability to the organization, and last but not least, cost savings to the program/organization.
As the labor gaps grow, it is important to identify the areas within the healthcare industry that are particularly susceptible to turnover and learn what we can do to either slow the rates down or bring them to a complete stop. While every healthcare organization is different in terms of its specific needs, culture and approach to dealing with this issue, where I work, Novant Health Presbyterian Medical Center Heart and Vascular Institute in Charlotte, N.C., we have customized and formulated a plan that has been successful for us. 
Below is Novant's plan to reduce turnover:
1. It all starts with the leadership — our leaders lead; we don’t boss.
The word “boss” as defined by the Oxford Dictionary is “a person who is in charge of a worker or organization”. If we examine the word through the lens of the verb “to boss,” it can help define the differences between a leader and a boss more clearly. The verb is informally defined as “to give someone orders in a domineering manner.” A boss, through his or her position of power, tells the subordinates what to do and expects the subordinates to act accordingly. A boss gives orders, making sure the people he or she is in charge of will do the job as required. Bosses do not ask or prefer certain actions, they expect and tell what needs to be done. The word boss carries with it a negative connotation, hence the word “bossy” when it comes to describing someone. 
If we examine the word “leader” in the Oxford Dictionary, it is defined as “a person who leads or commands a group, organization, or a country”. The distinction between boss and leader appears to be very subtle. Therefore, it would behoove us to examine the verb behind the word “Leader,” unveiling its true meaning. The verb “to lead” is defined as an act “to show (someone or something) the way to a destination by going in front of or beside them.” The word “leader” is thought to be someone who advises the subordinates and who does not just give orders, but actually takes part in the acts he or she also wants others to do. A leader is never a person who instructs and uses the power provided by the position. He or she will guide and support employees in reaching the required end objective. A leader will tell, and more importantly show, the direction and be a part of the journey to reach the destination. While the focus is still on getting the required jobs done, the emphasis with a leader is not solely in the result, but also on the process.
So we see that “leaders” motivate their employees, which then inspires employees to follow their leaders more closely. Bosses tend to push employees or direct them from the sidelines whereas leaders “lead” by example. 
Bob Chapman, author of the book “Everybody Matters” said, “Management is about telling people what to do, and leadership is about allowing people to do what they’re capable of doing, toward a common vision.” 
True leaders work alongside their employees. They clearly communicate objectives to the team and their actions are aimed at achieving goals together. This is the difference between inspiring team members and potentially losing the respect of the employees. When a team has confidence in a leader, it can help improve team culture and motivate employees to contribute. Points to keep in mind:
   • Leaders talk less and listen more, while bosses dominate the conversation.
   • Leaders do not let personal preferences get in the way of creating a dynamic environment. Bosses tend to create an “inner circle” that will, in time, decrease morale and productivity.
   • Leaders lead by example and get in the trenches with their teams. Bosses like to sit on the sidelines and only interact to give orders. This hurts team motivation, collaboration and creativity.
   • The leader will be more interested in the process and the people behind it. A boss is interested more about the outcome, not the process.
   • A leader approaches the work through innovation and collaboration (change is the driving force and the vision is the focus of the leader). A boss approaches work in an administrative fashion (a boss would have outlined a plan and accepted certain processes, which he or she will anticipate the subordinates to follow).
   • A leader receives his or her authority from an internal place (a leader has authority over subordinates because the subordinates hand it to him or her). The boss gets his or her authority from external sources (a boss is an authority figure because of a title, degree or from being the most qualified person for the technicalities of the role, but not necessarily the best at leading).
   • For a leader, accountability lies on his/her shoulders. The philosophy of learning from mistakes is at the heart of the leader’s strategy. A boss delegates responsibility and therefore, places accountability on the shoulders of the person performing the specific tasks. 
2. Chemistry is everything
Leadership consultant Bill Hogg was once quoted as saying, “Your organization is only as good as the talent you recruit. It is the people who define and shape the organizational culture — so identifying people with the right character, attitudes and behavior must be the highest priority when hiring or promoting within.”
How many leaders rifle through stacks of resumes to find the perfect person to fill a critical role, only to discover a few months later that they are completely disappointed in their choice? They look back and ask, “What did we do wrong? They appeared to have all the necessary experience.” As they ponder, the thought crosses their mind and they ask, “Or, was this more about the fit?” That is, the character and personality of the person that was hired. 
The mission set out by the leadership team at Novant Health Presbyterian Medical Center (NH PMC) cardiac cath lab has involved creating a well thought-out hiring process that gives priority to character, behavior and attitude over competence. 
Cardiac Cath Lab Manager Jeff Kittle, RN, BSN, RCIS, and Ruben Filimonczuk, RCES, AS-PMD, supervisor of invasive cardiology, cath lab and EP lab, sat down one afternoon to put on paper what this new “hiring process” needed to look like. We came up with several key points: 
A. Knowing Novant Health’s mission, vision and values: Frankly, most formal mission statements fail to embody adequate amperage to grab the attention of a workforce. Novant Health goes beyond the mission, vision and values of the organization, and include “Our People” and “Our Promise.” Our people credo states, “We are an inclusive team of purpose-driven people inspired and united by our passion to care for each other, our patients and our communities.” This is not a slogan. Our people credo articulates a unifying vision that aligns the organization’s engagement initiatives, patient-centered goals, and overall mission. True leaders will probe the statement and ask: “Are we an inclusive team? What is our unified purpose? Am I passionate about what I do?” The statement becomes a part of your belief system, not pretty words to be posted on the website of your organization. The statement is a compass held by leadership to help navigate their every decision.
B. Target their character: Character should not be confused with attitude. Character is how someone fits with your organization’s values and whether they conduct themselves in alignment with those values. Hence, the importance of first knowing and understanding the organization’s values. The potential candidate can have a bright, cheery, and pleasant attitude, but still not share the same values/character traits as those of your organization. Differences in character will always create disharmony in your organization. And, yes…I understand that specific skills are often essential in a specific role; however, no matter how skilled someone is, the wrong character and the wrong fit will eventually lead to issues. Once you have quickly eliminated those who do not have the basic required skill sets, focus on character and someone who has the right mindset that will fit and enhance your current culture, and who has the ability to hit the ground running.
C. Examine past behaviors: Having had the opportunity to interview many applicants throughout the years, I have learned that by adding behavioral-based questions to the mix (versus traditional questions alone) will help you determine if the applicant is likely to perform well in the job. Behavioral questions ask the applicant to describe actual past behavior on the job, which in turn helps you predict their future behavior. Conversely, traditional questions such as “What are your strengths and weaknesses? How do you define success?” and “Why should we hire you?” are more generic, with straightforward answers. Though these questions provide helpful information, behavioral questions reveal observable actions, attitudes and outcomes in specific job-related situations. Probe for situational examples of past behaviors that demonstrate their character in action. Focus more on how they did it (their character) and less on what they did (the skill) — listen for the “how” and focus less on the “what.” 
A few examples of “behavioral-based” questions we use are:
   • Describe a decision you made that was not popular and how you handled implementing it.
   • Have you ever made a mistake? How did you handle it? 
   • What do you do if you disagree with someone at work? 
   • Have you handled a difficult situation? How?
   • Give me an example of how you worked effectively under pressure.
D. Fill in the gaps: Potential candidates must have a certain level of competency, I agree, but skills should not be the focal point of the hiring process. Missing skills (to a degree) can be taught. Look for people who exhibit a willingness to learn, grow, and do what is best for the organization and the department. Training can be used to fill in skill and knowledge gaps, and people with good character realize this and will be willing to put in the time and effort to ramp up as quickly as possible. These are the people who will have the biggest impact on performance and will fit within your culture without making waves. Our team is a testament to that fact. Applicants with procedural skills in our area of expertise can be hard to come by at times, for various reasons. During the interview processes of our newest members, we looked for and applied the key points mentioned above to several nurses who lacked procedural experience. Their current contributions to our department have exceeded our expectations. Moreover, we know for certain we hired the right people for our team.
E. Use your team as part of the process: The entire team should be involved, and not just the leadership team, for the final interview step, because the lab’s culture and team approach is so critical to success. If someone does not impress their future teammates as they had impressed the boss, they might have a problem. When this is the case, the group and if need be, add an extra step to the process to make sure we are all on the same page. Another advantage this step provides is to cement the vision, culture, and team with the candidate. That candidate is forced to ask themselves, “Is this the right place for me?” It reaffirms to them that this is not just “a job” they have been looking at, but becoming part of a network of people who have created a culture and a team who work side by side effectively. Teams grow in a healthy manner when people take part in recruiting other people. 
F. Team or family: As humans we cannot help but feel the need to belong to something. One of our most powerful survival mechanisms in life is to be part of a group, a family, or a team. We as humans desire to interact and feel the need to be wanted and accepted for who we are and what we can offer to that group. There is a yearning to contribute to and take from that group of like-minded people. I have often commented and jokingly said to my team, “For as many hours as we spend together, like it or not, we are a family. A dysfunctional family at times, but nonetheless a family.” 
I tend to be cautious when utilizing the word “family”, however. In building and sustaining a healthy workplace culture, it is necessary to ask the question, “are we a team here, or are we a family?” A team has a common goal. The needs and positions of the team may vary, but the end result is to win. This means that teammates build up their fellow comrades, celebrate their successes, and encourage them when they have had a down moment. They come together to bond and unite for the greater outcome. At times, this may mean picking up the extra slack or offering to assist in an area outside of your “job description.” We do this willingly, because we know that when we put in the time, the team shares in the fruits of the labor, and that the commitment to that common goal benefits everyone.
Often times you hear businesses say, “We’re a family here.” Though that may be a good theory, difficulties remain, as you most likely will not fire a family member because they have been late 365 days in a row. While a family environment encourages personal relationships, a sense of community and a feeling of security, it may also discourage competition, lower expectations, or struggle with visible accountability.
In a team environment, expectations are clear, boundaries are set, and performance is key. In retaining top talent for the growth and success of the business, accountability, competition, and feedback are all important components in guaranteeing a team environment holds onto the right person. In a family environment, leadership will often hold onto employees that no longer share the same values, common goals, or are underperforming, all due to a sense of loyalty and emotional connections. In order to have a healthy balance, leadership needs to maintain a strong loyalty and respect for their employees, all while developing healthy expectations. It is up to leadership to cultivate the health and quality of life for the team just as you would a living being. A team needs attention and nourishment to flourish. Like any living organism, the needs of the members and the purpose of the team can change and evolve. 
3. Getting Cohesive as a Team
Every employee is different, with their own set of experiences, values, cultural backgrounds, influences and beliefs. The best leaders are those that can identify and appreciate the differences that one brings to the table and know how to put each one of them to full use. Good leaders must realize the opportunities and ability within each “dot” (employee) to enable their full potential, but leaders also need to be emotionally intelligent enough to recognize that they need to connect each dot. So, how is this done?
Work done in teams provides many advantages and benefits. Some of the major advantages are the diversity of knowledge, ideas and tools contributed by team members, and the camaraderie among members. A characteristic commonly seen in high-performance teams (as in our cath lab) is cohesiveness — a measure of the attraction of the group to its members and the resistance to leaving it. Those in highly cohesive teams will be more cooperative and effective in achieving the goals they set for themselves. Lack of cohesion within a team’s working environment will certainly affect performance, due to unnecessary stress and tension among coworkers. Therefore, cohesion (or the lack thereof) in the work place could, in the long run, signify the rise or demise of the success of an organization or company. But what most tend to overlook is that “cohesion” is the byproduct of a well-functioning, bonded team. Strong, functioning teams are not the result of coincidence. Team building and development takes time, accompanied by varied stages as people journey from being a group of strangers to becoming a united team with a common goal. What you will often see when new employees enter their new environments are that expectations are shared, ground rules are established, teaching is implemented, learning is obtained, and relationships begin to be built. After a certain comfort level is achieved, open dialogues begin to take place, members begin to settle into their respective positions, goals begin to take root, and ideas are shared. But with this stage can also come the “jockeying” for dominance in a certain role, power plays begin to surface, conflicts surface, confrontations ensue, and resentment walks in. What can bring this turbulent storm into a state of calmness? 
Trust, in essence, is the “glue” to bring about a cohesive team environment. One definition describes trust as a "reliance on the character, ability, strength, or truth of someone or something." Trust means that you rely on someone else to do the right thing. You believe in the person's integrity and strength, to the extent that you're able to put yourself on the line, at some risk to yourself. Trust is essential to an effective team, because it provides a sense of safety. When your team members feel safe with each other, they feel comfortable opening up, taking appropriate risks, and exposing vulnerabilities. Without trust there is less innovation, collaboration, creative thinking, and productivity, and people spend their time protecting themselves and their interests, wallowing in the quagmire of conflict and volatility. Teams achieve greater levels of participation and collaboration if their members trust one another, share a strong sense of team identity, and have confidence in their abilities and effectiveness. 
But trust obtained through leadership. And so we have come full circle. 
Good leadership at this point is imperative because trust will be obtained by the example that leaders set. If you want to build trust within your team, then lead by example, and show your people that you trust others. This means trusting your team, your colleagues, and upper management. Never forget that your team members are always watching and taking cues from you — take the opportunity to show them what trust in others really looks like. It is important to follow through on the promises you make, and to set an example not just for your team, but everyone else. Keeping your promises is incredibly important, because your word is often all you can give. Keeping promises and following through builds trust quickly, and can raise the entire group's morale, tone, and expectations. A point worth mentioning is that leadership is replicated, good or bad. 
Open communication is another essential component for building trust. Demonstrate that open communication is important to you by consistently sharing with the group. The more you share with your team members, and thereby prove that you have no hidden agenda, the more comfortable they will feel trusting you and each other. 
Another way that we have learned to develop team trust is to know each of the members personally. Do this by asking sensitively about their families or about their hobbies. Use judgement and caution, being careful not to invade their personal space. Personalities and characters vary, therefore learn to accept and invite differences. Begin by sharing something personal about yourself and your family. Lending pieces of information about yourself goes a long way in building mutual trust. Social activities and outings are other good ideas, but given the amount of time you spend with your team during the day, you can learn a tremendous amount over the course of just those hours. 
Last but not least, be cautious in playing the “blame game.” When people work together, honest mistakes and disappointments happen, and it is easy to blame someone as the cause. However, when everyone starts pointing fingers, notice how an unpleasant atmosphere can quickly develop. This lowers morale, undermines trust, and is ultimately unproductive. It quickly destroys everything the team has been working towards.
Instead, encourage everyone in your team to think about the mistake in a constructive way. Ask, “What can we do to fix what happened? How can we move forward together? And how can we make sure that this mistake doesn't happen again?” 
In conclusion, we are proof that cohesive teams drive organizational success, although developing and leading high-performance teams is one of the most complex tasks facing any leader in this current competitive work environment. Here at NH PMC cath lab, we have found that cohesiveness through trust is the key factor in constructing an effective, high-performing team, led by the example instituted by the leadership chosen by our organization. Although we have obtained the key components that brought us a successful team, keep in mind there were many trials to overcome along the path. But only through persistence have we been able to navigate through the rocky terrain.  
Editor’s note: Author Ruben Filimonczuk, RCES, AS-PMD, is the supervisor of invasive cardiology, cath lab and EP lab, at Novant Health Presbyterian Medical Center, Heart and Vascular Institute, in Charlotte, N.C.

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