The U.S. Healthcare system is really sick

For those working on the frontlines of healthcare, conflicting demands are a daily occurrence and source of debilitating stress. Despite these growing pressures, healthcare workers do their best to provide good care to millions. How long before the pressures placed on those providing direct care result in a collapse of the U.S. healthcare system. I spent four years consulting and working directly in and with dozens of healthcare organizations in over 37 states. And while there are exceptions, it appears much of the U.S. healthcare system is cracking. The only thing holding it together is the extraordinary and unsustainable sacrifices made by frontline staff and clinicians. They are keeping the U.S. healthcare system functioning, but at a high cost to their health and well-being.   

In healthcare, daily and moment-to-moment conflicting demands are the norm. Many hospitals, centers, and clinics I spent time in function almost exclusively in the RED zone of pressure and stress. Staff and providers live in a constant state of rushing, extreme multi-tasking, understaffing, long-hours, management demands, and over-whelming regulatory requirements. They do their best to listen to patients’ health and non-medical concerns during 5-15-minute exams while simultaneously reviewing and entering information into electronic medical records. 

They must provide care while adhering to ever-increasing regulatory and legal requirements. This occurs in a work environment where turnover, sudden resignations, burnout, and suicides have increased at alarming rates. As staff shortages become the norm, employees simply show up sick because there is no one to cover for them. Vacations and time off preferences go to individuals based on tribalism and those regarded as members of in-groups. All others are left to fend for themselves, which further exacerbates burnout and turnover.    

Healthcare professionals don’t go to work to become martyrs or be held up as heroes; however, that is occurring during the pandemic. They don’t want accolades, awards, or special recognition. They need working conditions that permit them to focus on patient care at a sustainable and safe pace. The push toward efficiency and optimal output, led by health insurance industry studies and process improvement consultants focused on cost savings, has pushed healthcare to its breaking point. 

During the years I spent my days working with nurses and other healthcare personnel, I became aware of a rather disturbing practice. Apparently, it is common and expected in some organizations for employees to be asked to officially clock out at the end of a shift and continue working with no additional pay. This practice shifts the labor cost from administrative responsibility and places it directly on frontline employees’ backs. The majority of these employees are women and people of color. Not only does this demoralize employees, it also hides the actual cost of providing care.  

Sometimes in group sessions, I ask participants to indicate by show of hands whether they go to work expecting to do an average job; no hands go up. When I ask how many go to work intending to do an above-average job, practically every hand goes up. I then ask, what gets in the way of you being your best? The response that consistently comes up no matter the hospital, city, or state is “we are understaffed.” What has caused turnover rates to increase from approximately 15 % in 2016 to almost 20% in 2019?  Part of the answer lies in how effectively organizational leaders listen to and act on employees’ concerns.  For example, the time required to maintain and update medical records is often at odds with clinicians’ needs to see and listen to patients. Both accurate record-keeping and listening to patients are needed to provide quality care. However, when healthcare providers are pressured into seeing more patients than can be reasonably scheduled, quality suffers, errors increase, and stress builds.

Overburdened healthcare organizations also tend to implement unsustainable, quick-fix solutions as rapidly as they can press send. Poorly thought-out quick fixes result in unintended consequences: increased medical errors, burnout, absenteeism, high turnover, and chronic stress. A physician’s assistant told me that the only way she gets time off is to call in sick, an ironic and desperate solution for some self-care. Another PA shared that she sees up to 30 patients a day. That’s about 18 minutes per patient if you don’t take breaks, eat lunch, go to the restroom, or do any charting. This occurs as regulatory bodies and management impose additional monitoring, compliance, and cost controls. 

An oncologist with small children shared that she regularly does her charting in bed, falling asleep exhausted. Asking employees to do more is not exclusive to healthcare. For many organizations during peak periods, it may be necessary to ask employees to make sacrifices; however, it should not become part of an enterprises’ ongoing business model. When healthcare organizations are overleveraged and struggling to close financial gaps, they push employees to choose temporary band-aid solutions, make unhealthy personal sacrifices, and endure chronic stress over months and years, leading to high turnover and staff shortages.   

Rarely are quick-fix solutions good options for solving long-term systemic problems. Functional and sustainable solutions take time and require stakeholder collaboration for defining accurate and mutually-agreed-upon definitions of the problem. In many so-called “right-sized” and hyper-efficient organizations, managers are compelled, even incentivized, to implement short-term solutions, sweeping their unintended consequences and employee concerns under the rug. It appears that only when problems cause significant financial losses, public embarrassment, legal action, or loss of life that root causes may get addressed. 

One area often swept under the rug in healthcare is the cause of employee turnover. In-home and nursing home care have the highest turnover rates in healthcare. It is not uncommon for turnover to be above 100 percent a year in many organizations. These are indicators that the working conditions and demands placed on staff are chronically and catastrophically unsustainable. Some healthcare leaders attribute high turnover rates to a supply problem. One study, “The RN Work Project reports an average of 33.5% of new RNs leave the bedside within the first two years.” Other studies indicate that as many as 50 percent of new RN’s/LPN’s leave the nursing profession within 3 years of entering it. 

Healthcare staff shortages are not a supply problem. They are a retention problem. Some healthcare organizations have lower-than-average turnover rates, which is proof that there are solutions to these challenges. Many healthcare administrators push tough issues down onto employees’ backs rather than up to leadership, boards, and policymakers, which is where they belong.     

Questions:

• What are the conflicting internal demands your employees experience as being at odds with organizational goals and values? For example: improving quality while increasing the number of patients seen in a fixed period.   
• What conflicting demands have you experienced before and during the pandemic?
• If you work in healthcare, what conflicting demands do you observe, and who is being asked or required to bear the brunt of an overburdened system?
• Do you see key stakeholder groups (frontline and direct care employees) authentically included in defining and recommending solutions to problems? 
• What behaviors can you observe where chronic problems are being addressed transparently and effectively?

Resource Links:
The American Epidemic: The U.S. Nursing
Shortage and Turnover Problem

https://mds.marshall.edu/cgi/viewcontent.cgi?article=1125&context=mgmt_faculty

• Author: John Rodríguez, MA
• Website: JohnRodriguez4Change.com
• Email: [email protected]