What works* Shortage Report.pdf · Nurse and physician roles are blurring in primary care, a...
Transcript of What works* Shortage Report.pdf · Nurse and physician roles are blurring in primary care, a...
PricewaterhouseCoopers’ Health Research Institute
What works*Healing the healthcare staffing shortage
*connectedthinking
Executivesummary
01 lKeyfindings02 lFutureForces03 lRecommendations04 lAbouttheresearch
05 Background:Businesspolicyissuesaroundthesupplyofnursesandphysicians
11 Thechallengesofinadequatesupply
20 Overcomingthedisconnect
22 Strategiesfordevelopingaworkforcemodelforthefuture
23 lDeveloppublic-privatepartnerships25 lEncouragetechnology-basedtraining27 lDesignflexibleroles31 lEstablishperformance-basedmetrics
35 Conclusion
36 Appendix
Tableofcontents
Executivesummary
Manynursesandphysiciansareamongthebabyboomerswhowillstarttoretireinthenextthreetofiveyears.Thefederalgovernmentispredictingthatby2020,nurseandphysicianretirementswillcontributetoashortageofapproximately24,000doctorsandnearly1millionnurses.Whilehospitalleadersvoicemuchoftheconcernoverpossibleshortages,theimplicationsextendthroughoutthelabor-intensive,trillion-dollarUnitedStateshealthsystem.It’sexpensivetoeducatenewnursesanddoctors.Taxpayer-fundedMedicarespends$8billionayearforresidencetrainingofphysiciansalone.1
WhiletheU.S.hasmorephysiciansandnursestodaythaneverbefore,theyarenotdistributedordeployedefficiently.Shortageprojectionstendtobebuiltaroundtoday’softendysfunctionalsystem,whichmakesthemproblematic.However,whilefutureshortagesarecertainlyworrisome,thebiggerissueforhealthindustryleaderstodayliesinorchestratingcareinanincreasinglycomplexandconverginghealthcarelabormarket.
Shortages,oreventalkofshortages,canmanipulatemarkets,creatingproblemsforhealthindustryexecutiveswhofacethedailyissuesofrecruitingandretainingthebesttalent.Yetbecauseshortageshavealsobeencyclical,short-termsolutionshavewonoutoverlong-termchanges.
Seekingsolutionsmeansunderstandingthatwhilethechallengesconfrontingnurseandphysicianshortagesareverydifferent,theirrolesandfuturesarestartingtoconverge.Healthcareisateamsport:adozenormoretypesofphysiciansandnursescanbeinvolvedinasinglepatient’scare,andtheneedforcoordinationandplanningbecomesmoreimperativeandcomplex.It’snotamatterofdeterminingthemixofnursesanddoctorstodeliverefficientandeffectivecare.Executivestodaymustconsiderwhatkindsofnursesanddoctorsareneeded,whattasksthesecliniciansarebesteducatedtodeliver,andhowtechnologyandlower-skilledworkerscanbeusedtosupplementorreplacethem.
PricewaterhouseCoopers’(PwC)HealthResearchInstitute(HRI)studiedthisevolvingissuewiththeintentofprovidinga360degreeviewofcurrentworkforcechallengesandprovidingaroadmapforanew,moresustainableworkforcemodel.
Keyfindings
Use of temporary nurses is no longer a stop-gap measure but has become a way of life for many hospitals.Reactingtoseveralyearsofnursevacancyratesinthe7%to10%range,hospitalexecutivessurveyedsaidtheyusetempnursesforanaverageof5%ofallnursinghours.Meanwhile,nearlythree-fourthsofhospitalexecutivessurveyedsaidtheirphysiciansareaskingforon-callpay,andtwo-thirdssaidsomeoftheirphysicianswanttobeemployedbythem.Thisdatabolstersthetrendofnursesmovingawayfromhospitalemploymentanddoctorsmovingtowardit.
The process of educating and retaining new nurses is broken.Thenumberofdeniedapplicantsfornursingschoolsisatitshighestever,increasingmorethansixfoldsince2002.Turnoveramongnewlyhiredhospitalnursesishighestinthefirsttwoyears.
Failure to retain nurses is costly and wasteful.Everypercentagepointincreaseinnurseturnovercostsanaveragehospitalabout$300,000annually.Hospitalsthatperformpoorlyinnurseretentionspend,onaverage,$3.6millionmorethanthosewithhighretentionrates.
Hospital leaders are in a state of denial about nurse dissatisfaction. Hospitalexecutivesbelievethatthenurseworkforceingeneralisdissatis-fied,butnotnursesintheirownhospital.Hospitalexecutivessurveyedcitedexcessiveadministrativepaperwork,patientworkloadstrainsduetorisingpatientacuitylevels,andinadequatestaffingasthetopthreefactorsfornursedissatisfactionandturnovers.Inadequatecompensationanddisruptivephysicianbehaviorrankedfourthandfifth,
•
•
•
•
respectively.However,hospitalexecutivesmaybeunderestimatingtheeffectsofthesefactorsbe-causemanyofthosesurveyedfailedtorecognizethesecomplaintsasa“verysignificant”problemintheirownorganizations.
A new wave of medical schools could repair the inequity of physicians in underserved areas and specialties.AsmoreU.S.medicalstudentsgraduate,they’lllikelydisplacesomeinternationalmedicalgraduateswhohavebeenfillingthegaps.Aftertwodecadesofthestatusquo,arecordnumberofnewmedicalschoolsareslatedtoopeninthenextfivetotenyears,whichcouldalterthefuturedistributionofphysicians.
Nursing education is stifled by perverse financial incentives.Whilemedicaleducationreceivessignificantfederalsubsidies,thesameisnotnecessarilytruefornursing.Nursingeducationprogramsoftenlosemoneyforcolleges,limitingcolleges’willingnesstoexpandtheirprogramsandraisefacultysalaries.
The workforce is too often a second thought for executives, who are distracted by numerous payment and regulatory issues.Asignificantdisconnectexistsbetweenwhathospitalexecutivesthinkaboutmedicalworkforceshortagesandhowtheyaddressthem.Three-fourthsofhospitalexecutivessurveyedsaidworkforceshortagesarereal.However,whenaskedtoranktheseshortagesasapriorityintheirorganizations,physicianissuesrankedsixthandnursingissuesrankedseventhbehindotherprioritiessuchasreimbursement,governmentregulations,clinicalquality,anduncompensatedcare.
•
•
•
•
1 PricewaterhouseCoopers
Theseresearchfindingsindicatethatthecurrentmedicalworkforcemodelisundergreatpressureandinmanycases,isbroken.Therearealsonewforcesonthehorizon,however,towhichhealthcareorganizationsmustbeabletorecognizeandrespond.
Nurse and physician roles are blurring in primary care, a specialty in which lower salaries have dissuaded debt-laden medical students.Three-fourthsofhospitalexecutivessurveyedsaidhospitalsareusingmorephysicianextenders,suchasnursepractitionersandphysicianassistants,andmorethanhalfsaidtheywillusetheminthefuture.Competitionforthesecliniciansisincreasing,particularlywiththeadventofretailclinics,whichheavilyemployphysicianextenders.
Rainmaker roles may change for hospitals. Employmentchangesandpay-for-performancereimbursementmaycombinetofliptheworkforcedynamicinhospitals.Traditionally,physicianswererainmakerswhobroughtinrevenue,andnurseswereoverhead.Throughnew,pay-for-performanceprogramsthatfocusonclinicalqualityandpatientsatisfaction,nurseswillhavesignificantimpactonthekeymetricsthatwilldrivereimbursementupdates.
Schedules trump salary.Organizationsthatfocusonthework/lifebalanceissuesforphysiciansandnurseswillhaveacompetitiveedgeinrecruitingandretainingtoptalent.Medicalstudentssaywork/lifebalanceisatopinfluencerofhowtheypickaspecialty,andnursessaycultureandschedulesarethegreatestinfluencesontheirjobsatisfaction.
Advances in specialization and technology are shifting what is done and by whom.Fromradiologiststocardiologists,todigitaltelemedicineandvirtualcolonoscopies,traditionalrolesanddescriptionsaremorphingandshifting.Thisshiftholdspromiseforincreasedefficiencybutmaycausedisruptionforcertainspecialties.
Futureforces
Whatworks* 2
Giventhesekeyfindingsandfutureforces,PwC’sHealthResearchInstitutehasdevelopedaroadmapforanewworkforcemodelbasedonthefollowingrecommendations:
Develop public-private partnerships.Widespreadshortageshavecreatedanenvironmentinwhichkeyhealthcareplayersmaynolongeroperateinsilos.Rather,thesegroupsmustworkcollectivelytopromotenursingandphysicianprograms,forgingalliancestoprovidenotonlyeducationbutalsorequiredfunding.
Encourage technology-driven training.Improvingclinicaloutcomesrequirestheseamlesscoordinationoftreatmentamongallclinicalprofessionals.Advancesintechnologyhaveenabledcaregiverstoworkinconcertwithoneanother,allowingthefocustoremainonqualitypatientcare.Providers,fortheirpart,mustmaximizeavailabletechnologyandencouragetheadoptionofandadherencetotechnicalinnovationstoincreasetheproductivityofmedicalstaff.
Design flexible roles.Morethanever,physiciansandnursesareplacedinastrongerpositiontodictatethetermsoftheiremployment,andemployersareincreasinglyfindingthatflexibilityiscentraltoattractingandretainingqualitymedicalstaff.Themostsuccessfulemployerswillprovideclinicianswithoptionsandintegrateflexibleworkarrangementsintotheirstaffingmodels.
Establish performance-based metrics. Unlikeotherindustries,healthcarehasbeenabletodelaytheadoptionofperformance-basedstandards.Traditionally,reimbursementdidnotdependonqualityoroperationalefficiencybutratheronlyonthevolumeofservicesdelivered.However,thelandscapeofreimbursementisevolving,withperformancebasedmetrics—suchasclinicalqualityoutcomesandpatientsatisfaction—asitscenterpiece.
Recommendations
3 PricewaterhouseCoopers
Toprovideresearch-basedinsight,HRIconductedmorethan40in-depthinterviewswiththoughtleadersandexecutivesrepresentinghospitals,academicassociations,nursingschools,andthebusinesscommunity.PwCconductedathoroughliteraturereviewofreportsandguidancefromassociations,regulators,andacademiatogatherinsightsoncurrentchallengesandbestpractices.Publiclyavailabledatawasanalyzedrelatingtoworkforceprojectionsanddemographics.PwCalsocommissionedasurveyofmorethan240hospitalexecutivesfromthroughouttheU.S.inthefollowingcategories:
ChiefNursingOfficer(CNO)
ChiefMedicalOfficer(CMO)
ChiefExecutiveOfficer(CEO)
ChiefFinancialOfficer(CFO)
ChiefOperatingOfficer(COO)
VicePresidentofHumanResources(VP-HR)
•
•
•
•
•
•
Whilethisreportfocusesonnursesandphysicians,theyarenottheonlyprofessionaloccupationsaffectedbyworkforceshortages.Otheroccupationsincludeimagingtechnicians,pharmacists,labtechnicians,andpatient-careassistants.2Whilethescopeofthisreportdoesnotallowfullexplorationofeacharea,thereissomecommonalityofsupplyanddemanddriversamongthedifferentfields.
TogetthebroadestpossibleinputfromPwC’snetworkofbusinessadvisers,HRIemployedaninnovativetoolcalledthePwCThought-Wiki,whichisbasedonsimilartechnologythatpowersWikipedia,anonlineencyclopedia.ThistoolincorporatedanewlevelofcollaborativeauthoringandknowledgesharingintoHRI’scontentdevelopment.TheThought-WikienabledPwChealthindustrypractitionerstocontributetheirreal-worldknowledgetotheresearch,anditwasespeciallyhelpfulincapturingthecollectiveintelligenceofourclinicians.
HRIalsoenlistedtheaidofPwCSaratoga,aservicethatfocusesonteamingwithexecutivesandHRdepartmentstohelpthemmeasure,manage,andmaximizethevalueoftheirworkforce.
Abouttheresearchh
Whatworks* 4
Registerednurses(RNs)andlicensedphysiciansarethearmsandlegsofthehealthindustry,anditseemsthereareneverenough.Three-fourthsofhospitalexecutivessurveyedbyHRIforthisreportsaidclinicalworkforceshortagesarereal.Asthehealthcareindustrygrowsandnowconsumes16%oftheoveralleconomyintheU.S.,employmentasanurseorphysicianhasdeliveredoneofthemostdependablepaychecksaround.Theneedfornursesandphysiciansinhospitals,nursinghomes,healthplans,pharmaceuticalcompanies,homehealthagencies,andotherhealthcompanieshasexplodedduringthepast20years.
Howmanyisenough?It’sadifficultquestiontoanswer,consideringtheacknowledgedinefficienciesofthesystemoverall.Intermsofglobalbenchmarks,theU.S.hasfewernursesandphysicianspercapitathansomeotherindustrializednations,yetitspendsfarmoremoneypercapita—twiceasmuchasotherindustrializedcountries—onhealthcare.Wouldhavingmorenursesandphysiciansraisecostsevenfurther?Woulditincreasequality?Woulditmakethesystemoperatemoreeffectivelyandefficiently?
Chronic nursing shortages may double after 2010
Thetotalnumberofregisterednurseshasincreasedby75%since1980(Figure1).Talkofnursingshortageshaswaxedandwanedforgenerations.Inrecentyears,atleastadozenstateshaveinitiatedstudiesabouttheshortageofnurses,andinsomeregions,chronicshortagesappeartobegrowing.Forexample,theRegionalMedicalCenterinMemphis,Tenn.reportedin2007itwassoshortofstaffthatithadtoresorttodivertingpatientstootherhospitals—evenwomeninfulllabor.3
Since1999,hospitalshavebeenonaconstructionbinge,heighteningcompetitionfornurses.Hospitalsspentanestimated$30billiononconstructionin2006—a30%increaseinjustoneyear—and83%ofhospitalsreporttheyplantoaddcapacityinthenexttwoyears.4Inaddition,Medicare’scasemixindexforinpatientsstartedtoriseagainin2001,5signalingsickerpatientswhoneedmorecare.ThisfindingwassupportedbyHRI’shospitalexecutivesurveythatrankedincreasedpatientacuityasatopreasonfornursedissatisfaction.Notsurprisingly,registerednursefull-timeequivalents(FTEs)peradjustedadmissionhavebeeninchingupafterdroppingduringmostofthe1990s.6Theneedformorenursestoworkinhospitalsgrew.Althoughhospitalsarethesinglelargestemployersofnurses,theyareincreasinglycompetingfortalentwithnon-hospitalorganizations,suchasambulatorycenters,physicianpractices,healthinsurers,anddiseasemanagementcompanies.Thepercentageofnursesworkinginhospitalshas
Background:Businessandpolicyissuesaroundthesupplyofnursesandphysicians
5 PricewaterhouseCoopers
Whatworks* 6
beendroppingsteadilyovertime(Figure2).Competitionisexpectedtoheatupevenmorewiththeadventofretailandworksiteclinics,staffedbynurses,nursepractitioners,andphysicianassistants.Over300oftheseclinicshaveopened,andanother1,200arescheduledtoopenby2009.7
In2006,direpredictionsabouttheshortageweretemperedwhenpolicymakersobservedaresurgenceofstudentsintheirlate20sandearly30sgoingintonursing.9Inadditiontoenteringtheworkforcelaterthanpreviousgroups,thoseborninthe1970sarenowenteringthenursingprofessioningreaternumbersthantheirpreviouscohortsdid.10
Evenso,thefuturetrendlookstroubling.Forthefirsttimeindecades,thetotalnumberofnursesisprojectedtobegingoingdownafter2010(Figure1).Nurseswillstarttoretireatthesametimethatbabyboomersbeginturning65yearsofageandstartusingmorecare.Currently,forecastsforaregisterednurseshortagein2020rangefrom400,00011tomorethan1million.12Animportantaspectoftheshortageisthatsome450,000licensednursesarenotworkingatthebedside.13Ifby2020allregisterednursesweretobeclinicallyactiveandworking,theshortageestimatefor2020woulddecreasetojustover100,000,mirroringtheshortagetoday.
Predictionsaboutthenursingshortagecouldbecomemoreacutewhencoupledwithnewpredictions
Figure 2. Percentage distribution of RNs by employer
OtherNursing education
Nursing homes/extended careAmbulatory care
1980 1984 1988 1992 1996 2000 20040
20
40
60
80
100
120
Public/community healthHospital
Source:HealthResourcesandServicesAdministration14
Figure 1. Licensed RN supply (past and projected)
1,500,000
2,000,000
2,500,000
3,000,000
1980 2020E1984 1988 1992 1996 2000 2004 2010E 2015E
Source:HealthResourcesandServicesAdministration8
7 PricewaterhouseCoopers
aboutanimpendingphysicianshortage.Theprospectofclinicalshortagesamongbothphysiciansandnursesmaybemorethantheindustrycanbear.“Thereexistsacertainecologyinthehealthcareindustry.Allofthepiecesdependupononeanother,butthereisnoincentiveorstructuretoviewitasawhole.Wehaveadysfunctionalsystemthatwe’retryingtofixwithsilverbullets,”saysDr.RobertTemplin,presidentofNorthernVirginiaCommunityCollege,oneofthelargestcommunitycollegesintheUnitedStates.
Forecasts of physician supply and demand are more ambiguous than for nursing
Thebasicdemographicforcesarethesameforphysiciansasfornurses:anagingU.S.populationdemandingevermorecareandenmasseretirementsofbabyboomerphysicians(currentlyone-thirdofallactivephysiciansareover55yearsold).15Asprofessionalsonthehighendoftheincomescale,physicianswhohaveplannedaheadfinanciallymaydecidetoretireearlierthannursesbecausetheycanaffordtodoso.Aswithnurses,theabsolutenumberofphysicianshasincreasedsteadilyovertheyears,outpacingpopulationgrowth.16However,thefutureisabitmurkier,complicatedbyspecialization,geographicmaldistribution,andblurringlinesbetweenprimarycarephysiciansandadvanced-practicenurses.Thebestfuturestrategyisanothermatter.Inpart,thismaystemfromstudiesshowingthatmorenursesincreasequality,butmorephysiciansmayaddmorecost.
Maldistributionofphysiciansbyspecialtyandgeographyhasexistedfordecadesbutisnoteasilysolvedbymarketforces.Factorsinfluencingthisaredifferencesinpay,lifestyle,culture,uncompensatedcare,andriskofliability.
Acrossallspecialties,theHealthResourcesandServicesAdministration(HRSA)predictsanetshortageof24,300physiciansby2020usingabaseorcontinuationcase(Figure3).17Thefederalagencyalsomodeledotherscenariosthatincludedproductivityimprovementsandincreaseduseofnurseextenders.Underthosescenarios,asurpluswaspredicted.
Awiderangeofopinionsexistabouttheadequacyoffuturephysiciansupply.AtthehighendisRichardCooper,M.D.,professorofmedicineat
Whatworks* 8
2000 2005 2010E 2015E 2020E
Figure 3. Active physicians: projected supply and demand
30% increasein enrollment
10,000 additionalgraduates in 2020
5,000 additionalgraduates in 2019
HRSA supply HRSA demand
700,000
800,000
900,000
1,000,000
LeonardDavisInstituteofHealthEconomicsoftheSchoolofMedicineattheUniversityofPennsylvania,whopredictsashortageofupto200,000physiciansby2020.18Atthelowendarethosewhoarguethatthemainproblemisoneofefficiencyanddistributionratherthanabsolutesupply.ThemedicalpracticevariationresearchstartedbyJohnE.Wennberg,M.D.,directoroftheCenterfortheEvaluativeClinicalServicesatDartmouthCollege,andcontinuedbyothers,hasshownthatthereisnocorrelationbetweengreaterphysiciansupply(afterarequisitethresholdisreached)andbetterclinicaloutcomes.Therearestillsignificantmedicalpracticevariationsunexplainedbypopulationordiseasecharacteristics.Infact,areaswithhighernumbersofphysiciansdonotnecessarilyimprovepatientoutcomes,buttheydoincreasecosts.19
Arecentpopulation-basedstudydemonstratedlowermortalityrateswheretherearemoreprimarycarephysicians,butnosucheffectwiththesupplyofotherspecialists.21AnotherrecentstudyfoundgreatvariationbetweenacademicmedicalcentersintermsofphysicianlaborinputsusedincaringformatchedMedicarebeneficiarycohortsinthelastsixmonthsoflife.22Thatis,thereweredifferencesinefficiency.Thisdatasupportstheideathatabsolutesupplyofphysiciansisaninsufficientvariableforunderstandingthe“shortage”problem.
Source:HealthResourcesandServicesAdministrationandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis20
9 PricewaterhouseCoopers
International recruitment has filled the gaps but isn’t viewed as a sustainable solution
NurseshavebeenemigratingtotheU.S.formanyyears,especiallyfromCanadaandthePhilippines.By2000,11%ofallU.S.nurseswereinternationalnursinggraduates(INGs).23By2005,13%ofallnewlylicensednurseswereINGs.24
Thepercentagescanbemuchhigherforanindividualfacilityorgeographicarea.MarthaSmith,formerassistantchiefnursingofficeratLaredoMedicalCenterinTexasandcurrentlyCNOatParkPlazaHospitalandMedicalCenterinHouston,describedhowthesituationcanbedifferentwhenlocatedalongtheU.S.-Mexicanborder.“WeoccasionallyreachfullcapacityandsometimescannotopenICU[intensive-careunit]beds.Weactivelyrecruitinternationalnurses—now25%ofourstaff—andIhavepersonallymadetworecruitingtripstothePhilippines.”
Intermsofthephysicianworkforce,internationalmedicalgraduates(IMGs)madeup25%ofallphysiciansinpracticeand26%ofnewgraduatephysiciansenteringpost-graduatetrainingin2005intheU.S.2526GraduatesofU.S.medicalschoolsarevirtuallyguaranteedaresidencyslottocontinuetheireducationtobecomelicensedphysicians.However,whentherearen’tenoughU.S.grads,thoseslots,typicallyinprimarycare,go
Personal story. Code Red in California
Rakeshlikestheexcitementandjobflexibilityoftheemergencydepartment,wherehecanworkasmuchoraslittleashewantsbypickingtheshiftshewantstowork.“IreallyliketheworkbecauseIdon’tknowwhattoexpect.Intheemergencyroomtherearetimesthatcanbemundaneandtimesthatcanbereallyexciting.Itkeepsmeonmytoes,andIseeavarietyofpatients.”
His career
Tenure 5yearsasemergencyroomattendingphysicianandemergencymedicalserviceliaison
Educationalfinancing
Scholarshipsandloans
%oftimeindirectpatientcare 95%
“Mycareerinmedicinestemmedfrommyinterestinthesubjectmatteralongwithmypastexperiencesasavolunteerintheemergencydepartmentandasalifeguard.”
The profession
“Medicinehasgivenmeagreatdeal.Ihavereallygottenalotoutofitandhavemetsomegreatpeople.Ifindalotofdoctorscomplainingandfrustrated,butIfeelthisprofessionisaprivilege.DoctorsinmanycountriesdonotmakeasmuchmoneyastheydointheU.S.,buttheyarepassionateaboutit.”Rakesh’sotherthoughtsabouttheprofession:
Peoplearenotalwaysawareoftheirownhealth
Theemergencydepartmentconceptcanbeabused,especiallybecauseaccesstoprimarycarecanbelimited
Toolittlepreventivecare.“Theemergencydepartmentreallyseestheeffectsofthis.Wefixtheshort-termproblem,butlongterm;theirhealthisnotgoingintherightdirection.”
•
•
•
Whatworks* 10
toIMGs.Oftheapproximately6,500IMGsenteringU.S.residencytrainingin2005,aboutthree-quarterswentintofirst-yearprimarycareresidencypositions.TheseIMGresidentsaccountedfor42%ofallinternalmedicineslots,37%ofallfamilymedicineslots,and24%ofallpediatricslots.27
However,only23%ofhospitalssurveyedbyHRIsaidtheyhadactivelyrecruitedforeigngraduates.Inaddition,accordingtotheHRIsurvey,only18%ofhospitalssurveyedsaidrecruitmentofforeignnursesanddoctorswasadesirablestrategytocombatfutureshortages.
Criticssaythequalityofnon-U.S.medicalschoolsishighlyvariable,andthatconcernisoneofthereasonstheAssociationofAmericanMedicalColleges(AAMC)hascalledforanincreaseinthesizeofU.S.allopathicmedicalschoolclassesandfornewschoolstobedeveloped.Whilesomeforeignmedicalschoolsareaccreditedbyrecognizedaccreditingagencies,manyhavenoaccreditationoraccreditationwithstandardsappreciablydifferentthanthosedictatedbytheLiaisonCommitteeforMedicalEducation(LCME),whichaccreditsU.S.andCanadianallopathicschools.
Forexample,thequalityofthistrainingisillustratedinthepassageratesontheU.S.MedicalLicensingExamination(USMLE).Passageratesforfirst-timetest-takersonthe2006USMLEStep2examination—whichreflectsfour-yearmedicaleducation—were96%forLCME-accreditedmedicalgraduatesand77%forIMGs;forrepeattest-takers,thesepercentageswere72%and50%,respectively.
Today’sLCME-accreditedallopathicmedicalschoolsintheU.S.reflectboththeartandthescienceofbecomingandpracticingasaphysician,whichgoesbeyondthelicensingexamscores.Anewemphasisoneffectivecommunication,empathy,andunderstandingtheimplicationsofpatientdiscussionsisembeddedintothecurriculum.Itisclearthatphysiciansmustbeabletobothcommunicateeffectivelyandtoartfullyincorporatequantitativeandqualitativeinformationintopatientcare.
11 PricewaterhouseCoopers
Nurses: More than 41,000 qualified nursing applicants were denied admission to nursing school (undergraduate and graduate programs) in 2005.28 This represents a sixfold increase since 2002.
Highvacancyratesandcontinuousturnoverofstaffarestressingthefinancialandculturalfabricofhealthcareproviders.29Itistellingthatnearlyhalfofallnursesdonotworkindirectpatientcare,andthatagrowingnumberofphysiciansareretiringearly.
“Wehaveanagingworkforceandinadequatenumbersofnewnursescomingintothepipeline,”saysAnnHendrich,RN,M.S.N.,FAAN,vicepresidentofclinicalexcellenceoperationsatAscensionHealthSystem.“Staffingdemandsatcurrentlevelsaredifficult.Whenyoucouplethatwiththenewconstructionunderway,it’snotagapbutacrevassethatwillmakeitverydifficulttoavoidshortfallsinaccess,patientsafety,andservice”(Figure4).
Howlargethatgapwillbecomeintheshort-termdepends,inpart,oneducatingnewnurses.In2006,hospitalsnationallyreportedan8.5%nursevacancyrate,accordingtotheAmericanHospitalAssociation.31Aftermultipledropsinenrollmentinthemid-tolate-1990s,nursingenrollmentbeganincreasingagainin2001.Infact,enrollmentsincreasedatdouble-digitratesduringthepastthreeyears.However,there’sbeen
Thechallengesofinadequatesupply
60s
50s
40s
30s
20s
1980 1990 2000 2004 2010E 2020E
Figure 4. Distribution of RN workforce by age group (thousands)
0
1,000
500
500
1,000
1,500
2,000
Age group
Source:AmericanHospitalAssociation30
Whatworks* 12
evenfastergrowthinthenumberofapplicantsturnedaway(Figure5).
Ashortageofqualifiednursingfacultyismostcommonlyblamedforthebottleneck.Asnursingshortagesbegantoappear,salariesbegantoincrease(Figure6).However,facultysalarieshaven’tkeptpace,socollegeadministratorssaytheycan’thiresufficientfacultytoexpandtheirprograms.Yetotherfactorsareatplayhere.Nursingeducationprogramsareexpensive.BrianFoley,actingprovostoftheMedicalEducationCampusofNorthernVirginiaCommunityCollege,states:“Welose$8,000peryearforeverynursewetrain.”Understandably,publiccollegesaren’tanxioustoexpandsuchprograms.Theirtuitionratesaresetbythestate,meaningtheycan’tsimplypassonthehighercoststostudents.Facultyoftenfindtheycanearnhighersalariesoutsideofacademia.Asaresult,thosewhoarequalifiedtoteachoftendon’t.Theaveragenursingfacultyageishigherthantheaverageageoftheoverallnursingpopulation,andthefutureofthenursingeducationsystemwillexperiencesignificantproblemsastheseinstructorsretire.
Anotherproblemforcollegesisthescarcityofclinicaltrainingsites.Overburdenedhospitaldepartmentsandstaffsareoftenreluctanttotakeontheadditionaltaskofteachingstudents.Someareaskingforpayment,therebyaddingtoacollege’seducational
Figure 5. Nursing slots vs. denied applicants
Denied qualified applicants (graduate and undergraduates)Nursing slots
2002 2003 2004 20050
20,000
40,000
60,000
80,000
100,000
Source:AmericanAssociationofCollegesofNursing32
13 PricewaterhouseCoopers
costs.“New[clinicalsites]arenotcomingonlinefastenough,”saysTemplin.“Allocationandutilizationofspacearearchaic.Thesystemisdysfunctional,withindividualorganizationsanddepartmentsoftentakingaparochialviewratherthanasystemapproach.”Compoundingtheproblemisthefactthathospitalsdonotreceivefederalfundingfortrainingnursesastheydoformedicalgraduates.
Physicians: The number of medical school graduates has remained relatively static over the past 25 years.34 The Association of American Medical Colleges has called for a 30% increase in medical school slots to meet shortages forecast by 2020.35
Thedynamicsofthephysicianpipelinearedifferent,buttheyculminateinsimilartalkoffutureshortages.Thetotalsupplyofphysicianshassteadilyincreasedeveryyearsincethe1970s(Figure7).A1980reportfromtheGraduateMedicalEducationNationalAdvisoryCommissionforecastedasurplusofatleast70,000physiciansby1990,apredictionthatwaswidelyacceptedandakeyfactorinlimitinggrowthinthenumberofmedicalschoolslots.36
Evenintothe1990s,physicianworkforcemodelsassumedthatsignificantchangesinpracticepatternswouldbewroughtbytheadventofmanagedcare—thatisagreaterrelianceonprimarycareandmoreefficiencyingeneral.
Figure 6. Hospital nurses' inflation-adjusted median annual earnings and number of hospital nurses
1,100,000
1,300,000
1,500,000
1,700,000
Median annual earningsNumber of hospital nurses
1996 1997 1998 1999 2000 2001 2002 2003 2004$35,000
$37,500
$40,000
$42,500
$45,000
$47,500
Source:InstituteofWomen’sPolicyResearchandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis33
Figure 7. Number of active physicians
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
1970 1975 1980 1985 1990 1995 2000
Source:BureauofHealthProfessions37
Whatworks* 14
AtulGrover,M.D.,Ph.D.,associatedirectoroftheCenterforWorkforceStudiesoftheAAMC,explains:“Webasedeverythingonassumptionsthatthesystemwouldchange.Webelievedthatmanagedcarewasgoingtosweepthecountry,thatitwasgoingtobeembracedbyphysiciansandpatientsalike.We’dallloveit.Itdidn’thappen.”
Asaresult,thenumberofmedicalschools(125)andslotsinU.S.allopathiceducationhasremainedrelativelystableformorethanadecade.Evenasthepopulationgrew,fewerstudentspercapitalwereenteringmedicalschool(Figure8).38’
Thedynamicsofmedicalschoolenrollmentarenowstartingtochange.Thefirstnewschoolin20years—FloridaStateUniversityCollegeofMedicine—graduateditsfirstclassofstudentsin2005.40Moreschoolsareunderdevelopment(Figure9).Mostofthenewschoolswillbebuiltinareaswithhighpopulationgrowth,andgraduatestendtolocatenearwheretheyaretrained.
Whiletherearestillplentyofapplicants(2.2applicantsforeveryslot)seekingentrytothisverylongtrainingpipeline,thenumberofmedicalschoolslotshasbeenrelativelystaticformanyyears.Asinnursing,thereareworriesaboutolderdoctorsretiringandseniorsneedingmorecareafter2010.Recognizingthelongpipelinetobuildschools
Figure 8. First-year MD enrollment per 100,000 population
4
5
6
7
8
1980 2020E1985 1990 1995 2000 2005 2010E 2015E
Source:AssociationofAmericanMedicalColleges39
Source:AssociationofAmericanMedicalCollegesandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis41
Alaska
Hawaii
Florida
Louisiana
MississippiGeorgia
Alabama
South CarolinaArkansas
Texas
North CarolinaTennessee
New Mexico
OklahomaArizona
Kentucky
Virginia
MarylandDelaware
KansasMissouri
West Virginia
Colorado
New JerseyIndiana Ohio
Nevada
Utah
California
Rhode IslandConnecticut
Pennsylvania
Illinois
Massachusetts
NebraskaIowa
Wyoming
New York
Vermont
New Hampshire
Michigan
South Dakota
Oregon
Wisconsin
MaineNorth Dakota
Idaho
Montana
Washington
Minnesota
Figure 9. Medical school enrollments & forecasted medical school additions by state, 2006
University of California(Merced & Riverside)
Arizona State University & University of Arizona(Phoenix)
University of Texas(El Paso)
Texas Tech University Health Sciences Center(El Paso) University of Houston,
Methodist Hospital, & Cornell University (Houston)
University of Central Florida (Orlando)
Florida International University (Miami)
University of North Carolina & Carolina Medical Center(Charlotte)
Virginia Tech University & Carilion Health System (Roanoke)
Mercer University(Savannah)
Touro University(Florham Park)
Beaumont Hospital & Oakland University(Auburn Hills)
Northeastern Pennsylvania Education Development Consortium (Scranton)
University of Washington (Spokane)
300-399200-299
600-699400-499
Over 1,000800-899
100-1990-99
Number of matriculates
15 PricewaterhouseCoopers
andthenumberofyearsrequiredtoeducateandtraindoctors,theAAMCin2005calledfora15%increaseinmedicalschoolslotsandthenoneyearlaterdoubledthatcalltoa30%increase.42
Amongthoseinterviewed,opinionsdifferedonphysicianshortages.Certainlytherearegeographicandspecialtygaps,suchasinneurosurgeryandinhospital-basedspecialties,suchasradiology,anesthesiology,andpathology.Andthere’salwaysbeenregionalmaldistributionofphysicians.Forexample,MassachusettshastwiceasmanyphysicianspercapitaasMississippi,and20%ofAmericansliveinaprimarymedicalcareshortagearea,asdesignatedbyHRSA(Figure10).4344TheNationalHealthServiceCorpsisdesignedtoaddressshortagesthroughtuitionreimbursementincentives,butithasbeenregardedaschronicallyunderfunded.Studentsrecruitedfromunderservedareasaremoreapttoreturntothoseareasandpractice.Suchstudentsaremorelikelytobefromminoritygroups,yetblacksandHispanicsstillconstituteonly4%eachofthephysicianworkforce,withsimilarratiosseeninnursing.45
Not a HPSA
Full primary care HPSAPartial primary care HPSA
2002 County HPSA status
Figure 10. Primary care health professional shortage areas
Source:AmericanAcademyofFamilyPhysicians46
Whatworks* 16
Theerosionofinterestinprimarycare,however,remainsthemostcriticalproblem.ThenumberofU.S.medicalgraduateschoosingtheprimarycarespecialtiesoffamilymedicineandgeneralinternalmedicinehasplummeted50%inthepast10years.47Only20%ofinternalmedicineresidentsnowchoosegeneralinternalmedicine—thatis,primarycareinsteadofa(higherpaying)subspecialty.48TheAmericanAcademyofFamilyPhysicianshascalledfora39%increaseinfamilymedicinephysiciansbasedonitsassessmentoffutureneed.49Amajorunknownfactorinanyforecastofprimarycarephysicianneedistheextenttowhichsub-specialistsprovideorwillprovideprimarycareserviceswithintheirownpractice.
Physicians and Nurses: Financial pressures influence education, career paths, and staffing.
Whilemanyentermedicineforaltruisticreasons,moststudentsalsolookatreceivingareturnontheirinvestment.Theerosionofstudentsgoingintoprimarycaremaybelinkedtosalariesthathaven’tkeptpacewiththerisingcostofeducation(Figure11).Theaverageeducationalindebtednessfor2006medicalschoolgraduates(includingpre-medborrowing)hasballoonedtoapproximately$130,000.50In2006,theaveragedebtofgraduatingmedicalstudentsincreasedby8.5%comparedtothepreviousyear.51
Personal story. Frontier medicine
KateworksinPresidioCounty,Texas,oneofthelargestandpoorestcountiesintheU.S.“Ifyouliveinafrontierarea,youbetternotgetsick.Therearehardshipsjusttogetthebasicneedsmet.Iftheoneambulanceisoutonarun,youhavetoimprovise.Manypeoplearebornhere,andtheydon’twanttoleaveorcan’taffordtoleave.Thisisaplacewhereyouhavetodrivethreehoursjusttogetyourteethcleaned.”
Tenure 9yearsasRN,11asnursepractitioner
Educationalfinancing Loans
%oftimeindirectpatientcare 80%
Her career
“IdecidedtobecomeanursepractitionerbecauseIwasfedupwiththesystem.Nursinghasstruggledtobeascientificprofessionbecauseofthebasicnursingprocessofnotdiagnosingortreatingbutfollowinganursingcareplan.Thatwastoolimiting,andIfeltlikeIwasalwaysworkingwithmyhandstied.”
The profession
“Weneedtohaveclinicianscollaboratemoreasteamsandclearlydefinethedifferentjobsandroles.Nursesoftenshootthemselvesinthefootbynotdifferentiatingbetweenthedifferentlevelsofeducationthatprepareyoufordifferentjobs.Butmostimportant,weneedtochangethewholesystemandgeteveryoneaccess.”Kate’sotherthoughtsabouttheprofession:
Professionalnursesshouldhaveaminimumofabachelor’sdegree
Internationalmedicalgraduatesareessentialtoruralareas;theyareincrediblymotivatedandhighlytrained
Shegetsfrustratedwithphysicianswhodonothaveaholisticapproachtohealth
•
•
•
17 PricewaterhouseCoopers
Asdebtreacheshigherlevels,thereisagreaterinfluenceonspecialtychoice.52Graduatesself-reportthatotherfactorsdrivetheirspecialtychoice.53
Whilepayranksthirdasanursesatisfier—behindworkingconditionsandscheduling—aroughcorrelationhasbeendemonstratedbetweennursepaylevelsandnumbersofnursesintheworkforce.55Nurseshortagesresultintheuseofagencynursesatahigherrateofpay.Tominimizeagencystaffingandensurecoverageandviabilityovertime,executivesareaddressingpayissuesfornursingstaff(Figure12).
Physiciansaremorefrequentlydemandingon-calllevelsofcompensationorareoptingoutofemergencydepartmentandtraumacoveragecompletely.Theyarealsoincreasinglyseekingemploymentarrangements.Thisdatademonstratesthegrowingdesireofyoungergenerationsforwork/lifebalanceaswellasameansofensuringadequatecompensation,whichtrackscloselytooverallworkforcetrends.
Source:AmericanAssociationofMedicalCollegesandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis54
Figure 11. Monthy physician debt obligations vs. monthly income (before taxes)
$12,000
$12,250
$12,500
$12,750
$13,000
Monthly debt obligationsMonthly income
2002 2003 2004 2005$800
$900
$1,000
$1,100
Source:HealthResourcesandServicesAdministration56
Figure 12. Actual and real average annual salaries of full-time RNs
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
1980 1984 1988 1992 1996 2000 2004
Actual salary (dollars)Real salary (dollars)
Whatworks* 18
Inthesub-specialtyarena,somephysiciansarechallengedwithrisingcostsanduncompensatedcare.Asaresult,someobstetrician/gynecologistshavedroppedobstetrics;somephysicianshavemovedtostateswithliabilitycaps;andsomeareseekingadditionalreimbursementthroughstatesandothersources.JamesF.Caldas,presidentofWashingtonHospitalCenterinWashington,D.C.,says,“Weoperateinaverychallengingmarketforhealthcare—onethatisparticularlyharshforobstetricians.Inresponsetotheskyrocketingmalpracticepremiums,manyoftheprivatepracticeobstetriciansinthismarkethavelefttheDistrictofColumbiabecausetheysimplycouldnotaffordtheexorbitantcostofinsurance.Wehaveexcellentobstetriccoverageatourhospitalonlybecauseweemploythephysiciansdirectly.”
Hospitalexecutivesalsovoicedconcernaroundotherspecialties—suchasneurosurgery,generalsurgery,andorthopedics—forcoverageintheemergencydepartment.Theriskofliabilityanduncompensatedcarehasbecomesogreatinsomeareasthatitisdifficultforhospitalstofindsuchcoverage.Thisisaggravatedbyrisingutilizationanddiminishedcapacityinemergencydepartmentsnationally.57Thesephenomenawilldrivegeographicandspecialtydistribution,perhapsevendrasticallyinthefuture.
Personal story. The lure of specialty medicine
Specialistsliketobeonthecuttingedge,takingcareofcomplicatedcases.Daksha’scareerstartedinacademiatobeclosertotheresearchandspecializedequipment,butvolumeswerenothighenough.“Theacademiclifewasgood,buttherewasnotenoughworkspecifictomypractice.”
Tenure25yearsasob-gyn;4yearsasreproductiveendocrinologist
Educationfinancing Personalfinancing
%oftimeindirectpatientcare 80%
Her career
“Iwanttohelpdiagnoseandtreatpeoplewithraremedicaldisorders—oratleastsupportthemwhenIcannottreatthem.Ilikethechallenge.”Dakshatreatsproblemsrelatedtothereproductivesystem,suchashormonaldisorders,menstrualproblems,pregnancyloss,infertility,andmenopause.
The profession
“Ithinkthatwiththeadvancementoftechnology,physiciansmustbemoreproactiveaboutlearning.”Daksha’sotherthoughtsabouttheprofession:
Dealingwithinsurancecompaniescanbefrustrating
Sometimescurrentinsuranceguidelinesdonotmeettheclinicalneedsofpatients
•
•
19 PricewaterhouseCoopers
Regulationcanimpactshortages.Forexample,inCaliforniain2004,thelegislaturemandatednursestaffingratiosinhospitals.Thevastmajorityofhospitalshadbeenincompliancewiththeratiospriortothelaw,butthosethatweren’thadtoscrambletocomply.Unfortunately,themandatewasnotaccompaniedbyanyinitiativestoenhancethenumberofgraduatesthroughadditionaleducationalfundingorothermechanisms.Asaresult,manyhospitalscontractedwithagencynursesathigherexpense,ortheyeliminatedotherstaff,suchaspatientcareassistants,topayforadditionalnurses.RickMartin,seniorvicepresidentofpatientcareservicesandCNOatHoagHospitalinNewportBeach,Calif.says:“Whileourfacilityabsorbedthecostsofmaintainingourpoolofnursingassistantsinthefaceofthemandatedratios,manyfacilitiesdidnot.Thecostburdenofthesemandateswillincrease,andthesituationwilldeterioratefurtherwhenthestatutoryratiofortelemetryunitsincreasesfrom1:5to1:4.Thischangewillfurtheraggravatethenursingshortageandstaffingchallengefacedbymanyproviders.”
Source:PricewaterhouseCoopers’HealthResearchInstituteSurvey58
Figure 13. Involvement with initiatives (all respondents)
75% 80% 85% 90% 95% 100%
Quality improvement
Information technology
Patient safety
Recruitment & retention (nurses)
Operational process improvement
Recruitment & retention (physicians)
Consumerism
Facility construction (new or expansion)
Joint venture
Whatworks* 20
Overcomingthedisconnect
Afterseveralyearsofnursingvacanciesthatrangedfrom7%to10%,hospitalexecutiveshavelearnedtosustainoperationsbysupplementingwithtemporarynursesasnecessary.Astheworkforceshortagecontinuestogrow,thenumberofsupplementalRNsandlicensedpracticalnursesisprojectedtogrow57%by2012.59AccordingtotheHRIsurvey,hospitalsareusingtempstosupplementabout5%ofnursingworkhoursonaverage,resultinginalowvacancyrate.Dependingontheorganizationalculture,executivesmayperceivethisscenarioasasustainablesolution.
Hospitalexecutivesareexperiencinginitiativeoverload.RecruitmentandretentioninitiativesmustcompetewithmanyotherhospitalprioritiesaccordingtoanHRIsurveyofhospitalexecutives(Figure13).
Accordingtothesurvey,workforceissuesareprioritizedlowerthanallothercomplexissuesexceptformanagedcarecontracting(Figure14).Thisdisconnectseemstoindicatethathospitalexecutivesdonotyetfullyappreciatetheimpactofworkforceissuesonotherstrategicinitiatives.Considerationoftheavailabilityoffinancialresourcesasaninputtoplanningiscommonplace;however,humancapitalisnotalwaysgiventhesameconsideration.Failuretoconsiderhumanresourceconstraintscanleadtofaultyplanningandaninabilitytoimplementkeystrategies.Inaddition,hospitalexecutivesarenotalignedregardingprioritization.CNOsandvicepresidentsofnursingandhumanresourcesprioritizenursestaffingandclinicalqualityhigherthandohospitalCEOs,CFOs,andCOOs(Figure15).
21 PricewaterhouseCoopers
Inaddition,nursingleaderspointtoseriousfracturesinthesystem.Onestudyshowedthat40%ofU.S.hospitalnursesreportedjobdissatisfaction,andmorethan43%demonstratedhighlevelsofburnout.62Nearly23%ofU.S.nursessaidtheyplannedtoleavetheircurrentjobwithinthenextyear.63Fornursesunder30yearsofage,thatfigurewas33%.64Almost55%wouldnotrecommendtheprofessionasacareerchoice.65Acommonlyheardphraseis“lovenursing,hatethejob.”
Manyhospitalsarerecognizinganeedforchangeinthecaremodelinvolvingbothnursesandphysicians.OfthehospitalexecutivessurveyedbyHRIforthisreport,oneinthreesaidtheywereintheprocessofimplementingnewnursingmodels.
Manynursesgraduatebutdonotpursuenursingasacareer.Ofthosewhodo,halfleavetheirfirstemployeraftertwoyears(Figure16).Thiscanindicateseveralthings:nurseeducationprogramsarenotproperlypreparingstudentsregardingwhattoexpectonthejob;organizationsarehiringnursesintoaninflexiblemodelthatdoesn’taccommodatewhatyoungnurseswanttoputintoandgetoutofnursing;andtheproblemsthatcreatedissatisfactionamongnursesaren’tbeingaddressedsufficientlybyhospitalleadership. Source:PricewaterhouseCoopers’HealthResearchInstituteSurvey61
(1 is the least important 5 is the most important)
1
2
3
4
5
Figure 15. Prioritization of complex issues among healthcare organizations
CEO, CFO, COO
Government reimbursement
Clinicalquality
Governmentregulation
Nurse Staffing
Physicianstaffing
Managed carecontracting
CNO, VPs of Nursing and HRCMO
Figure 14. Hospital executive rankings of hospital issues/priorities
Ranks Overall rank
Reimbursementfromgovernmentpayers 1
Clinicalquality 2
Governmentregulations 3
Reimbursementfromcommercialpayers 4
Uncompensatedcare 5
Nursestaffing-generalorspeciality 6
Physicianstaffing-generalorspeciality 7
Managedcarecontracting 8
Source:PricewaterhouseCoopers’HealthResearchInstituteSurvey60
Whatworks* 22
TheHRIsurveyshowedadisconnectonnursedissatisfaction.Whenaskedaboutcommonfactorsthatdrivedissatisfaction,hospitalexecutivessurveyedsaidnoneofthosewereamajorfactorintheirorganizations(Figure17).
Anyfuturenursingmodelshouldaddresstheprimarydissatisfiersthatdrivenursesoutoftheworkforcetoday.Manyofthefeaturesmaybegroupedundertheheadingofprofessionalautonomybutalsoincludeaspectsofpracticestandardsandtechnicalinfrastructure.Takenasawhole,theydescribeamorehighlytrained,effective,andautonomousprofession.
Strategies for developing a workforce model for the future
Ourresearchindicatesthathealthcareorganizationsneedtodesignasustainableworkforcemodelthatincorporatessolutionsfromtrainingtoretaining.Tothisend,PwChasdevelopedfourkeystrategies—detailedinthefollowingpages—thatassistinprovidingablueprintforanimprovedmedicalworkforcemodel.
Source:NationalLeagueforNursingandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis66
Annual applicants for basic RN programs
Annual admissions into basic RN programs
New nurses leave first job within 2 years
Pass licensure exam
Annual graduates from basic RN programs
320,000
145,410
~52%
74,327
78,476
Figure 16. The system is leaky
Source:PricewaterhouseCoopers’HealthResearchInstituteSurvey67
Figure 17. Factors for nurse dissatisfaction/turnover
1.0 1.5 2.0 2.5 3.0
Excessive employee cost sharing for benefits
Scheduling; mandatory overtime
Reliance upon agency nurses
Unpleasant or inefficient physical environment
Not enough direct patient care activity
Lack of information technology support
Inadequate preparation/training
Disruptive physician behaviour
Inadequate compensation
Workload too heavy due to inadequate staff
Workload too heavy due to acuity levels
Excessive administrative paperwork
23 PricewaterhouseCoopers
Inmanyregions,providersandeducatorshavebandedtogetherinvariouswaystoaddressthenurseandphysicianshortagesthroughprivateandpublicfunding,loanerinstructors,promotionalcampaigns,flexiblework-studyprogramsforadvanceddegrees,andleadershipinterventionsthatpromotethevalueofnursingandteaching.Communityoutreachprogramstohighschoolsandevenmiddleschoolscaninfluencestudentsatayoungage.TheRobertWoodJohnsonFoundationcampaignwascitedbymanyintervieweesashavingapositiveimpactontheimageofnurses,aswellasprovidingscholarships.Innovativecurricularapproachesarebeingtestedtospeeduptheeducationaltimeline.
Bettercommunicationbetweenhealthcareorganizationsandkeystakeholderssuchasgovernmententities,schools,andthebusinesscommunityiscritical.Dualappointmentscaninjectmoreclinicalfacultyintotheteachingenvironment,dominatednowbyanagingfacultyoftenlongremovedfromthebedside.Somestatesareprovidingloanforgivenessfornursingstudentswhopursuegraduateeducationandlaterteachnursingundergraduatesinstateschools.Forexample,Tennesseelauncheda$1.4millionpublic/privatepartnershipinwhichapproximately$1millionwasprovidedbythehealthcareindustry.69
AnumberofstateshaveenteredintotheNursingLicensureCompact(NLC),whichallowsanursetohavealicenseinonestateandtopracticeinanothercompactstate—subjecttothatstate’spracticelawandregulation.70Theseagreementsallowformorerapidtransferoflicensednursesacrossgeographicareas,whethertorespondtochangingdemandfornursingservicesortoreactintimesofcrisisornaturaldisaster.
Intermsofphysicians,themedicalschoolsnowonthedrawingboardreflectstrongregionalpartnershipsdirectedatlocalneeds.Physiciansoftenprefertopracticeneartheirresidencies.Becauseofthedroughtinnewmedicalschoolsoverthelasttwodecades,regionswithhighpopulationgrowthhavenothadacorrespondingincreaseinmedicalgrads.That’schanging,thankstoeffortsinhigh-growthstatessuchasFloridaandTexas,wherethere’salsoashortageofHispanicphysicians.
AnotherleadingmodelthataddressesunderservedareasisinWashington,Wyoming,Alaska,Montana,andIdaho,wherethemedicalschoolinWashingtondrawsonremotetrainingsitesintherespectivestatesformedicalstudents.71Thisarrangementisviewedasmoreeconomicalthanbuildingnewmedicalschools,anditaddressestwobasicissues:offeringeducationalopportunitytostudentsinstateswithoutmedicalschoolsandplacingtraineesinunderservedareas,therebyincreasingthechancetheywillpracticethere.Oregon,Kentucky,andotherstatemedicalschoolsareexpandingremoteplacementoftraineestothissameend.
Developpublic-privatepartnerships
Casestudy.NorthernVirginiaHealthcareWorkforceAlliance
Whatworks* 24
NorthernVirginia,whichincludessomeofthenation’sfastestgrowingcounties,createdtheNorthernVirginiaHealthCareWorkforceAlliance(theAlliance)tofacilitatearesponsetothegrowingshortageofhealthcarepersonnel.TheAlliancecomprisesproviders,businesses,academicinstitutions,economicdevelopmentagencies,workforceinvestment,andcommunityleaders.72Allianceleaderssaytheeffortwasoneofthefirsttimestheproblemhasbeenaddressedbyabroadrangeofinvolvedparties.
Todate,theAlliancehashelpedobtain$1.2millionfromthestatetoenhanceeducationalcapacity,andthosefundsarebeingmatchedbylocalhospitalsandhealthsystems.Inaddition,theAlliancefacilitateda$1.2milliongrantfromtheU.S.DepartmentofLaborfortrainingimagingpersonnel.NorthernVirginiaCommunityCollege,asaresult,hasexpandeditseducationalprogramstoreachnewgraduationgoalsfor2009.TheAlliancealsoisdevelopingamethodtoquantitativelymeasureitssuccessinproducingnewgraduatesandreducingtheclinicianshortage.
Inhealthcare,asinmostindustries,itisrareforcompetitorstocollaborate.However,inthiscase,leadersfromlocalhealthsystems,thebusinesscommunity,highschools,communitycolleges,anduniversitiescametogethertoaddresstheintertwinedproblemsandsolutionscontributingtotheshortage,suchascredentialingandclinicaltrainingsites.ManyoftheAlliancemembersalsonowserveontheGovernor’sHealthReformCommission,sharingtheirknowledgewithotherportionsofthecommonwealth.
Thegroup’sfirstgoalsincludedobtainingobjective,quantifiableinformationoncurrentandfutureworkforcechallenges,identifyinggapsinthecurrenthealthcareworkforce,andseekingprovenbestpracticestoclosethegaps.TheAlliancestudiedtheregionalmarkettounderstandthedynamics,includingpopulationtrends,economicfactors,educationallevelsofthepopulation,currentandfuturehealthcaredeliverychangesincludingconstructionandexpansion,anddiversityoftheworkforce.Aprimarytrendwasthehighcostofshort-termincentives.Providershadbeenaggressiveinconfrontingthestaffingchallenges;however,thecostsinherenttothisactionweredeemedunsustainableovertime.
TheAlliancealsonotedthatwhiletheregionfaceddemographicchallengescommontootherareas,uniqueregionalcharacteristicscompoundedtheproblem.Forexample,theregionhashigheconomicgrowth,ahighlyeducatedpopulation,lowunemployment,ahighcostofliving,andadiverseandimmigrantpopulationthatisnotcurrentlyreflectedintheworkforce.73
Basedontheresearch,theAlliancedevelopedsolutionsthat:
Recognizetheimpactofshortagesontheregion’slong-termeconomicandbusinesscosts
Acknowledgetheneedtotapintothediverseimmigrantpopulationinthearea
Developleadingretentionpractices,suchascareerladders
Partnerwithareaemployers,theeducationalsystem,andbusinessestointroducehealthcarecareerstoyoungstudents
•
•
•
•
Recommendations
Collaborate across a region.Educationalinstitutions,healthsystems,andbusinessesmustworktogethertodevelopandimplementincentives—suchasflexiblescheduling,loanforgivenessorstipends,andfaculty-specificbenefits—toenticenursesintofacultypositions.Considerationshouldalsobegiventoeasethetransferofresourceswithinaregion,particularlyasitrelatestolicensurerequirements.
Seek understanding. Buildinggoodpartnershipsrequiresthatpartnersspendtimelearningtounderstandeachotherandacknowledgeeachother’sprioritiesandhowtheyworkonaday-to-daybasis.Bringingtogetherallofthestakeholderswhoshareintherisksandrewardsofthisissueisfoundational—andcanbechallenging.Partiesmaywanttobringinoutsidefacilitatorsinregionswithahistoryofcompetitionorconflict.Thepayofffortheseeffortscouldbelong-termsustainabilityoftheentireregionalsystem.
Operationalize the strategy. Recognizethateffectiveandsustainablepartnershipsneedtoworkatboththestrategicandoperationallevels.Toprovidethedesiredresults,allhigh-levelplanningandstrategyneedstobefollowedbycomprehensiveandfocusedplanstooperationalizethestrategyandachievethevision.High-levelplanningneedstobebackedupbysoundoperationaleffectivenessandsolidexecution.
Adapt as needed. Continuouslyreviewandmonitorthepartnershipandresultstoensurethatthecollaborationremainsfocusedonthevisionandisachievingitsdesiredmission.Thismaymeanchangingtackwhereitappearsappropriate,adaptingtochangesinthemarketplace,andevolvingwithregulatoryandotherchanges.Allpartiesshouldworktogethertoensurethattheeducationandcertificationrequirementsareadaptingtothechangingclinicalenvironment.
Measure results. Assesstheinitialstartingpointasthecollaborationcommences,anddevelopperiodicmeasurementstomonitorprogressandresultsachieved.Establishingeffectiveanddata-drivenperformancemeasuresforthepartnershipwillhelpensurethatthevisionisachievedandallowforadjustmentstobemadeasnecessary.
25 PricewaterhouseCoopers
Whiletherehasbeensomeinnovationintheeducationalenvironmentfornursesandphysiciansovertheyears,progresshasnotkeptpacewithtechnology.Thetransferofclinicalknowledgeandcognitionisgenerallyexcellent,buttheskillsrequiredtothriveinthenewworldofhealthcarearenotalwaysbeingimpartedeffectively.Graduatesneedtobepreparedforthatworldviarelevantlearningexperiencesandtechnology.
Patientsimulatorscanprovideclinicaltrainingscenariosthatmimicaparticularpatientpathologybyusingcomputersimulationmonitoringsystemsthattrackclinicianperformancegradesagainstinstitutionallyestablishedbestpractices.Remotedistancelearningcanbeusedtoexpandeducationalprogramstounderservedareas.Interdisciplinarymodelsandroleplayingcanbeusedintheclinicalyearsoftrainingtofosterteamwork,communication,mutualrespect,andpartnershiponsuchinitiativesasclinicalqualityandpatientsafety.Clinicalexpertiseofnurses,pharmacists,nutritionists,andrespiratorytherapistsmustbebroughttothebedsideassharedresourcesinconcertwithphysicians’work,asopposedtoeachspecialtyfunctioninginseparatesilos.Consumerismcreateddemandforamedicalworkforceeducatedinthebasicsofcustomerfocusandhowtorespondtotheincreasinglyinformedpatient.“Hospitalsthathaverespondedtothatconsumermind-sethavereapedtherewardsofincreasedpatientsatisfaction,”indicatesWilliamPowanda,vicepresidentofGriffinHealthServices,aDerby,CTbasedhospitalsystem.
Recommendations
Integrate technology into new educational models.Newtechnology,suchaspatientsimulators,allowsstudentstopracticewithvariousclinicalscenariosanddeveloptheirdiagnosisandtreatmentskills.Thiscanresultingreateraccuracyandincreaseexposuretovariedclinicalencounters,leadingtoimprovedoutcomes.
Embrace consumerism. Virtualroleplayingshouldbedevelopedandincorporatedintothecurriculumandusedasameansforstudentstogainpracticeincommunicatingwithbothpatientsandotherpractitioners.Itwillhelpstudentsimprovetheirbedsidemanner,adopttransparencyfordealingwithincreasinglyeducatedpatientsandcolleagues,andlearnandutilizeeffectivecollaborationskills.Theseeffortswillimprovetheirconfidencewhentheyencountersimilarexperiencesintheclinicalsetting.
Make information technology competency a requirement.Nursesshouldaccepttechnologyasameanstobecomemoreeffectiveandefficientwithnon-patientcareduties.ThroughtheuseofelectronicmedicalrecordsandWeb-basedtools,paperdocumentationisminimized,transparencyisincreased,turnaroundtimescanbedecreased,andcontinuityofcarebecomesamoreseamlessprocess.Inordertobeofutmostvalue,however,technologyapplicationsmustbefullyembracedandintegrated.Effortstoeducateandinvolvetheclinicalstaffinimplementationcanimproveacceptanceofthesenewtechnologies.
Encouragetechnology-basedtraining
Casestudy.Nursingeducationmeetsthestarshipenterprise
Whatworks* 26
Traditionally,nursingschoolshavereliedonusedmedicalequipmentdonatedbyhospitalsandthedidacticteachingtechniquesassociatedwithatypicalclassroom-styleeducationprogram.Today,nursingeducationleadersarepushingforchange.ElizabethPoster,deanattheUniversityofTexasatArlingtonSchoolofNursing(UTASN)says:“Wecan’tjustdothesamethingforeverandexpecttohavedifferentoutcomes.Thetraditionaleducationthatwe’veallseenoverthelasthundredyearsneedstochange.”
UTASNisoneofthelargestnursingschoolsintheU.S.andgraduatescloseto200B.S.N.studentsannuallywitha99%passrateontheNationalCouncilLicensureExaminationforRegisteredNurses(NCLEX).Theschoolisnowinphasetwoofathree-phaseSmartHospitaldevelopment.Whencompleted,itwillincludemorethan100,000squarefeetand60bedsofteachingspace.TheSmartHospitalisalaboratoryofvirtuallearningandsimulationthatleveragestechnologytosupplementfaculty.Ineffect,technologybecomesafacultyextender.“Wearemovingawayfromthe‘Ilecture,youlisten,Itestbypaperandpencil’approach.Bygettingthestudentsmorecomfortablewiththepsychomotorskillsfirst,whichwecandoinsimulation,thenthehourswedospendinthehospitalaremuchmoreproductivehours.Aftersimulationtraining,theyreallycanhitthegroundrunning,andtheycanbemoreperceptivetopatientandstaffneeds,”saysBethMancini,UniversityofTexasatArlingtonassociatenursingdean.
TheSmartHospitalfeatures:
Full-bodypatientsimulatorsthatincludeinfant,child,adult
Birthingmannequinsandhigh-fidelitymannequinsthatreplicatephysiologyfunctions
Virtualintravenousdevices
Simulationsoftwaretoconductrealisticscenariosandrole-playingactivities
Monitoringandrecordingequipmentthatenablesmultiplesimulationsandwhat-ifscenariosforfacultyreviewandevaluationaswellastimeandmotionstudies
•
•
•
•
•
Butcantechnologyandsimulationincreasethesupplyandhelpnursesre-entertheworkforce?Itisestimatedthatapproximately500,000nursesaren’tworkingintheprofession.74Mancinisaysyes:“Therearenursesoutthereinthecommunitythataren’tworkinginhospitals,andwewantthemback.Soweneedtohelpthemacquiretheknowledgeandskillstheyneedinamannerthatfitstheirschedulesandpreparesthemtoworkatthebedside.CanweputtheminourSmartHospitalandgivethemthecompetenciestheyneed?Absolutely—notaproblem.”
Posterconcludes:“Simulationandcomputerizedmannequinsgivethefacultymorecontroloverwhatstudentsseeandexperience,sowhentheygraduatethey’remoreconfidentandmorecompetent.Thiscansignificantlychangethelearningtimelinewhen,forexample,inthehospitalsetting,insteadofhavinganinternshipforsixmonthsorayearandcosting$45,000to$70,000,maybethatdoesn’tneedtohappenanymore.”
27 PricewaterhouseCoopers
Lifestyle,notsalary,isatopreasonthatmedicalstudentsciteforselectingtheirspecialty,accordingtothe2006MedicalSchoolGraduationQuestionnairepublishedbytheAAMC.75Eventoday’sphysiciansarechoosingbetterwork/lifebalance;studiesshowthatphysiciansareworkingfewerhoursonaveragethaninthepast.BeverlyJordan,vicepresidentandCNOatBaptistMemorialHealthCareCorp.inMemphis,Tenn.relatesaconversationshehadwithasecond-generationphysicianwhorecentlycompletedtraining:“Thisyoungdoctorindicated:‘Mydadpridedhimselfonhowmanyhoursheworked.WhenIwasgrowingup,myfatherdidn’tknowwhetherIhadabike.Iwanttoteachmychildrentoridetheirs.’”
Dr.CarySennett,seniorvicepresidentofstrategyandcommunicationsattheAmericanBoardofInternalMedicine(ABIM),relatesthestoryofastudentwhosays:“IreallyappreciateMotherTeresa,butthat’snotme.”Sennettsaysthatstudentsareweighingthedebtburdenandlifestyleissues.“StudentslookatthevalueequationofhowmuchamIgoingtoearnversushowmuchoutofmyhide?”
Employmentmodelsforphysiciansandnursesarechangingasmorephysiciansareaskinghospitalstoemploythem—atleastpart-time.“Systemsmoreandmorehavetosupplementaphysician’sincome[thatis,payingforon-callhours],”saysLeisaMaddoux,vicepresidentofoperationsatCenturaHealthinDenver.“Withashortageofcertainspecialists,physiciansareunwillingtotakedaysanddaysoncall.Emergencydepartmentcoverageisdifficultbecausedoctorsdon’twanttoexposethemselvestosignificantlyhighlevelsofuncompensatedcare.”
Technologyischangingjobdescriptionsforphysiciansaswellasnurses,creatingtheneedforflexibility.Radiologistsarenowdoingsomeoftheworkthatcardiologistsdid,utilizingdiagnosticcomputerizedtomographyscansofthecoronaryarteriesinsteadofinvasiveangiography.Likewise,cardiologistsarereplacingsurgeonsinsomeproceduresasmorepeople
chooselessinvasivetreatments,suchasstents,toaddresscoronarybypassconcerns.Interventionalradiologiststreatcerebralaneurysms,whichwasoncethedomainofneurosurgeons.Virtualcolonoscopiesmayeliminatetheinvasiveprocedureasnowperformedbygastroenterologists.DigitaltelemedicineisallowingX-raystobereadovernightinIndia,psychotherapytobeconductedremotely,andmammogramstobescreenedautomaticallythroughdigitalscanning.Thisexplosionoftechnologyapplicationsholdsnotonlythepromiseofmoreefficientandmoreeffectivelydistributedcarebutalsothepotentialforsignificantdisruptionforcertainmedicalspecialties.
Toolsthatcanreducenon-patientcaredutiesfornursescanimproveefficiencyandsatisfactionwhencoupledwithprocessimprovements.Thegoalistousetechnologyeffectivelyandmaximizepatientcaretime.Asnursesadopttechnology,thereis“areducedtimeofshiftchangeandinturnincreasedfacetimewiththepatient,”saysPamHudson,vicepresidentofKaiserPermanenteHealthConnectTM.“Thepatientexperienceswarmerhand-offsbetweennurses,andthenursesexperienceimprovedwork/lifebalancewithreducedovertime.Patientsaremoreinvolvedintheircareastheyareabletoviewtheirchartandlabinformationonin-roommonitors.”TheprimaryfunctionalareaswhereITtoolscanbeimplementedforbesteffectare:
Documentation,suchasbedsidewirelesstrans-missiontomonitorsandelectronicmedicalrecords
Medicationadministration,suchascomputerizedphysicianorderentry,barcoding,androboticdelivery
Locationandretrievalofpatients,suppliesandequipment—suchasbarcoding,radiofrequencyidentification,andelectronicpatientprogressiontracking
Communications,suchasone-and-donecalls:immediateresponsesfromattendingphysicianversusmakingmultiplecalls
•
•
•
•
Designflexibleroles
Whatworks* 28
Withopportunitiesforclinicianstoworkwithambulatorycenters,healthplans,andpharmaceuticalcompanies,hospitalsmustfindtheircompetitiveedge.“Nursesleavebecauseofculturalissues:theyareleavingthecultureoftheorganization,”saysLilleeGelinas,vicepresidentandCNOofVHAInc.“Moneyisthenumberoneattractor,butthenumberoneretentionandemployeeengagementfactorisstateoftheculture.”Somehospitalshaverespondedbyusinginternalregistriesandothertoolsthathelpnursesfeelmoreincontroloftheirworkandpersonalschedules.Asmorephysiciansseekemployment,thesameissuesfacingnurseretentionmaybecomeanissueforphysicianretention.
Manyviewtheprospectofadvancedpracticenursesandphysicianassistantsasfillingorsupplementingprimarycarerolesatalowersalarycostandtrainingrate(Figure19).“Giventheever-growingexpectationsforpreventiveservicesandchronicdiseasemanagement,itmaynotbehumanlypossibleforprimarycarephysicianstodoallthatweareaskingofthem.Therearewaysthatpracticescanbeorganizedandleveragedthatcouldincreaseefficiency,butmostphysiciansaren’tusedtothinkingabouthowtomanageworkflowandoptimizesystemsforpatientcare,”saysABIM’sSennett.
Thepotentialfornon-physiciansubstitutionbyextendersorothertypesofhealthcarepractitionerscanprovideaboostforclinicalproductivity.Ononehand,physiciansmayhavetorelyincreasinglyoncollaborativeworkwithadvancednursepractitioners.77Ontheotherhand,convenientandwidespreaddiagnosticandtherapeutictechnologyincreasesconsumerdemand,puttingfurtherpressureontheworkforce.
Technologyadvancesmayyieldnewdeliverymodelsaswell.“Deliveringcarefromadistanceisamodelthatwillcome.Wecanargueaboutthetiming,butitwillmaterialize,”predictsRobertPearl,M.D.,executivedirectorandCEOofthenation’slargestmedicalgroup,thePermanenteMedicalGroup.“Our6,000physiciansallutilizeelectroniccommunicationswiththeirpatients.Asanexample,patientscansendtheirphysiciansasecuree-mailwithaquestionrelatedtoaproblemthatisnotamedicalemergency.Thephysiciancanrespondlaterthatday,andtheinformationisavailableanywherethepatienthasInternetaccess.Asaresult,medicalcareisprovidedinawaythatisconvenientforboththepatientandthedoctor.Additionally,inKaiserPermanente,patientscanrequestprescriptionrefills,scheduleappointments,andreviewtheirlaboratoryresultsonline24hoursaday,sevendaysaweek.Thisapproachisoptimalinorganizationsthatareprepaidfortheirservices,butovertime,allpaymentmodelswillneedtorecognizethisservicetofacilitatewidespreadadoption.”
Source:BureauofLaborStatisticsandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis76
Figure 19. Comparison on 2004 salaries
Registered nurse
Physician'sassistant
Nursepractitioner
Family/generalpractitioner
0
$30,000
$60,000
$90,000
$120,000
$150,000
$180,000
Generalinternists
29 PricewaterhouseCoopers
Recommendations
Develop a range of physician compensation models.Asphysiciansbecomemorecloselyalignedwithhospitalsandlooktohospitalsasemployers,hospitalsneedtodevelopcompensationoptionsthatrewardthemforperformance.Thesemodelsneedtointegratenewpaymenttriggerstocompensateforperformance,quality,andintegratedcare.Themodelsalsomayneedtobecustomizedforphysiciansindifferentspecialtiesandindifferentstagesoftheircareers.
Personalize scheduling.ShiftbiddingisanInternet-basedprogramusedbyhospitalstofillopenshifts.Thesystemworksbyallowingnursestobidonopenshifts;thenursewhoplacesthelowestbidonashift,withthebidamountstillgreaterthannormalwages,winstheshift.Shiftbiddingwasoriginallycreatedasameanstoenhanceorsupplementnurseschedulingmethodsbuthasevolvedintoaprimary-shiftschedulingprogram,asitcanbetailoredtofithospitalpoliciesandprocedures.78Thecostsassociatedwithashift-biddingsystemaregenerallylowerthanwithtemporarystaffingagenciesandprovideagreateramountofefficiency.Asanaddedbenefit,theshift-biddingsystemcanincreasenurseautonomywhileboostingoverallemployeemorale.Manyhospitalshavereportedanincreaseinretentionasaresultofutilizingtheshift-biddingsystem.St.PetersHospitalinAlbany,NewYork,hasbeenusingashift-biddingsystemsince2001andclaimsasavingsofmorethan$1.7millionandadropinnursevacancyratefrom11%to5%.SpartanburgRegionalHealthcareSysteminSouthCarolinareportsthatshiftbiddinghasdroppeditsnursevacancyratefrom20%to7%.UseofthissystemhasenabledSpartanburgRegionaltocutnurseoutsourcingbymorethan90%,resultinginasavingsof$10,000to$20,000perweek.79Suchefficienciesarepromptingsomehospitalstoprovideincentivesforemployeestousethebiddingsystem,suchasearlypaymenttothoseemployeeswhoscheduletheirshiftsthroughtheWeb-basedsystem.Additionally,organizationsshouldconsiderotherflexiblestaffingoptions,includingjobsharing,offeringoptionstoretiredorretiringstaff,uniqueshiftopportunities,andotherinnovations.
Use internal registries and eliminate supplemental staffing.Internalregistriesfunctionsimilartoahospitalownedandoperatedstaffingagency,inthatthehospitalcreatestheregistry’spoliciesandproceduresandhascompletecontroloveritswagesandbenefits.Theseregistriesallowhospitalstoeffectivelyreacttoarangeofvariablesthatrequireadditionalstaff—suchascoverageduringvacationandsicktime,leavesofabsence,andbedopenings—withouthavingtodependonanexternal
staffingagency.Withaninternalregistry,ahospitalcaneliminatesupplementalagencyfeesandinsteadpaycompetitivewagestotheregistryemployeeswhilestillensuringasavings.80Temporarystaffingcanharmstaffcohesion.AnInstituteofMedicinestudyreportsthatincreaseduseofagencynursesisassociatedwithalackofcontinuityofcareandcreatesvulnerabilitytoqualityproblemsanddiscontentonthepartofphysiciansandnurseswhomustworkwithtemporarystaffunfamiliarwiththeworksetting.Thisinturncausesdisruptioninateamculture.81Temporarynursesareoftencompensatedathigherlevels,withthebasicper-diemmark-uprangingfrom25%to40%abovetheaverageemployee’swage.Thistranslatesinto$250,000to$400,000thatthehospitalispayingjustforanagency’sserviceandoverheadcostsforevery$1millionspentonsupplementalstaffing.82
Consider going through the Magnet Recognition® Program process. Thejourneytowardthiscertificationprovidesvaluableprocessimprovementsforhospitals.TheMagnetRecognitionProgram,developedbytheAmericanNursesCredentialingCenter(ANCC)torecognizehealthcareorganizationsthatprovidenursingexcellence,hascertified242nursingorganizations.83Whilethecredentialitselfmaybeeffectiveinrecruitingnurses,intervieweessaidthattheprocesstowardMagnetstatuswasbeneficialinforcingtheorganizationtoexamineitsstructureandprocessesrelevanttothenursingworkforce.Giventhesignificantcostofobtainingthedesignation,eachhospitalshouldweighthecostandbenefitindividually.ThemanagementinterventionstiedtoMagnetstatuscanhaveapositiveimpactonnursesatisfactionandretention.Featuresofrecognizedhospitalsaresharedgovernance;focusonsupervisoryeffectiveness;schedulinginnovation;performancemeasurementandfeedback;qualityimprovement;andinterdisciplinaryworkingrelationships.ThecreationofaMagnetculturealsohasbeenshowntoimprovepatientqualityoutcomes.84
Measure the organizational fit.Somehospitalsareusingtoolsthatgaugeanapplicant’sfit.Dr.RosemaryLuquire,formerseniorvicepresidentandchiefnursingandqualityofficeratSt.Luke’sEpiscopalHealthSysteminHoustonandcurrentseniorvicepresidentandCNOatBaylorHealthCareSysteminDallas,says:“Ourutilizationofanorganizational-fithiringmodel,whichhelpsensureagoodmatchwithnursingingeneralaswellasspecialtyareas,hasprovedtobeofgreatvaluetooursystem.Oursuccesswasobviousduringthefirst18monthsfollowingimplementationasourturnoverratesdroppedsignificantly.”Evenpriortoemployment,clinicalpreceptorshipscanbondtraineestotheorganization.
Whatworks* 30
Think ergonomics.Ergonomicdesignsregardingthephysicaldemandsoflifting,otherrisksofinjury,excessivewalkingorstanding,andinadequatevisualdisplayareunderstoodtobesignificantfactorsinretainingworkforce,especiallyforthosewhoareaging.DonStubbs,vicepresidentofhumanresourcesandriskmanagementatSt.Joseph/CandlerHealthSysteminSavannah,Georgia,summarizesthechallenges:“Asthepopulationandourpatientscontinuetogetheavierandheavier,we’redevelopingwaystodealwiththeseissues.We’recurrentlyjustoverayearintoaprojectwherewehaveprovideduser-friendlyliftingandhandlingequipmenttoassistnurseswithpatientcare.Werecentlyhadapatientforwhomstaffneededequipmentjusttolifttheindividual’sleg,whichweighedover120pounds.Wecannotexpectournursestomeetthisneedwithoutassistance.”
Walk the walk.Settingthetoneatthetopcanchangethecultureofanorganization.ThomasE.FitzJr.,FACHE,ispresidentandCEOofSt.Mary’sHealthCareinAthens,Georgia,afacilitythathasreceivedrepeatedrecognitionforqualityandwasnamed2006LargeHospitaloftheYearbytheGeorgiaAllianceof
CommunityHospitals.Hesummarizesthephilosophytheyemploy:“WehaveintentionallycreatedacultureatSt.Mary’s.Peopleunderstandtheyaregoingtoworkhardhere,buttheyenjoyworkinghere.WehaveborrowedthemottofromSouthwestAirlines:‘Nowhiringhardworking,fun-lovingindividualswhowanttomakeadifference.’Thisphilosophyhaspaidoffforusinmanyways,includingsignificantimprovementsinretention.Inonedepartment,wehad75%annualturnoverjustafewyearsago;thatdepartmentnowhasawaitinglist.”Thechangesdidnottakeplaceimmediatelyandrequiredmanyinnovativeactions.Theyincluded:
Implementationofadedicatedandstructuredleadershiptrainingprogramforallmanagementstaff
Committedtransparency,includingfrequentcommunicationsandbulletinboardsoneveryunitwithfinancial,quality,andstaffingmetrics
Dailystand-upmeetingsintheCEO’soffice,whereallexecutivesmeeteachdayforaveryshortperiodtoallowforimmediateactiononpriorityissues
•
•
•
Personal story. Quality of life
Likemanyclinicians,Lauriemadehercareermovesbasedonherabilitytobalancefamilyneedswithworkschedulesandcareeradvancement.“Ihavetakenpaycutstoworkinaprivatepracticesettingandinautilizationandcasemanagementrole.Atonepoint,Ileftthehospitaltogoworkinprivatepracticeforacardiologist.Ihadtwoyoungchildrenandwantedmorepredictablehours.Iammotivatedbyfamily,andthatmeansmoretomethanmoney.”
Tenure 25yearsasRN(8inprivatepractice;restascasemanagerandinformaticist)
Educationfinancing Loans
%oftimeindirectpatientcare 63%
Her career
“Iwaskindofpushedintonursingbymyfamily.Mystepmotherandfourofmysistersarenurses.TherewereloanforgivenessprogramswhenIwenttoschool,andthisplayedheavilyinmycareerdecision.WhenIbeganmycareer,itseemedtobemorepatientcenteredthanitistoday.Manytimespeoplenowseemtobemoremotivatedby‘What’sinitforme?’”
The profession
“Ourprofessionisverydatadriven.Myjobasaclinicalinformaticististoperformclinicalandqualityreportingforourhospitalfacilities.IsupervisetheCMSqualityindicatorreporting.”Laurie’sotherthoughtsabouttheprofession:
Nursingisagreatprofessionbecauseyoucanworkanywhereinthecountry
Shegetsfrustratedbyphysicianswithbigegos
•
•
31 PricewaterhouseCoopers
Establishperformance-basedmetrics
Beautyisintheeyeofthebeholder,andqualityisviewedthroughtheeyesofthepatient.Qualityisincreasinglybecomingthedriverbehindpay-for-performancereimbursementbyMedicareandcommercialhealthplans.Qualityisbeingmeasuredbyclinicaloutcomes,processmetrics,andpatientsatisfaction.Nursesareaboutthreetimesmorenumerousthanphysiciansandarekeylinksinthequalitychain,ensuringthatroutineproceduresareperformedcorrectly,patientsaremonitored,dataarerecorded,medicationsaredeliveredcorrectly,andpatientsarecomfortedintheirdailyneeds.
Understandingthelinkbetweencaregiversandpatientsatisfactioniscriticalforearningbonusesundernewpay-for-performancemethodologies,saysWilliamPowanda,vicepresidentofGriffinHealthServicesCorp.GriffinisalsotheparentorganizationofPlanetree,a125-hospitalorganizationcommittedtohumanizing,personalizing,anddemystifyingthehospitalexperiencebycreatinghealingenvironmentsandengagingpatientsintheircaretreatmentandwell-being.GriffinistheonlyhospitalnamedbyFortunemagazineasoneofthe100BestCompaniestoWorkForforeightconsecutiveyears.“Wehaveadoptedthephilosophythatprovidinginformationforpatientsallowsthemtoparticipateintheirhealthcareinwaysthatwillimprovetheiroutcomesandsatisfaction.Weprovideinformationforpatientsabouttheirmedicalproblemandthetreatmentandcaretheywillreceiveinanumberofways,includingdiagnosis-specificpatientpathways.Weallowpatientsfullaccesstotheirmedicalrecords,tests,andanyinformationthatmaybenefitthem.Themodelisattractivetopatientsandstaff.Ourpatientsandstaffaremoresatisfied.Wehavebecomethehospitalofchoiceforthecommunityserved,andourattractivenessasanemployerisextremelyhigh,withover7,200applicantsforour160openpositionslastyear.”
Beginningin2008,thefederalgovernmentplanstopublishpatientsatisfactionscoresonindividualhospitals.Morethanhalfofthepatientsatisfactionsurveyfocusesonthequalityofcareprovidedbynursesandphysicians.Questionsinclude,“Duringthishospitalstay,howoftendidnursestreatyouwithcourtesyandrespect?”and“Duringthisstay,howoftendidthehospitalstaffdoeverythingtheycouldtohelpyouwithyourpain?”
VoluntarycollectionofthepatientsatisfactiondatabeganinOctober2006,andresultsareexpectedtobepublishedontheCentersforMedicare&MedicaidServices(CMS)websiteinearly2008.ThereportingispartofMedicare’sbroadpay-for-performancequalityinitiative.Hospitalsmustparticipateiftheywanttoreceivethefull-marketbasketupdateforfiscal2008.Thosethatfailtoparticipatewillreceivetheupdateminus2.0percentagepoints.Thiscouldsliceahospital’sreimbursementincreaseinhalf,sincethemarketbasketupdatehasbeenaround4%inthepastfewyears.Hospitalsmustsubmitapledgeforminthesummerof2007statingtheirintentiontoparticipate.Inaninterestingtwist,theMedicarePaymentAdvisoryCommission,theagencythatadvisesCongressonMedicarepolicyandpayment,hasrecommendedthatthegovernmentreducesomeofthefundingforphysiciantrainingtopayforthequalityinitiative.
“Wehavefoundthatastablenursingworkforcewithexperienceatthefacilityaswellaswithspecificpatientpopulationscombinedwithgoodcommunicationswiththephysiciansleadstohighquality,”saysDr.DavidPryor,seniorvicepresidentofclinicalexcellenceatAscensionHealth.“Thedataiscleartous.Thereisacomponentofcommunicationandteamworkthatmustbepresentintheenvironmentinordertoprovidehigh-qualitycareandretainstaff.Nursesareprovidingfrontlinecare,andnurseturnoverisdirectlyrelatedtoeffectivecommunicationonthefloor.”Nursesatisfaction
Whatworks* 32
leadstostaffstability,whichleadstoimprovedclinicalandfinancialoutcomes.Onadailyoperationallevel,nurseshortagescanleadtodisruptionsofoperatingroomscheduling,diversions,andbedclosures,allofwhichhaveadirectimpactonphysicians.Ofcourse,physicianstaffinggapscanthemselvesleadtotheseproblems.Nursingandmedicinehavetoooftenoperatedinfunctionalsilos,buttheyareinfactcloselylinked,aswillbecomemoreevidentinthefuture.
Hospitalemployeeturnoverhasbeencorrelatedwithahigheradjustedmortalityindexandseverity-adjustedaveragelengthofstay,aswellasahighercostperdischarge.85PatientsinhospitalswithhighRNstaffinglevels(75thpercentile)hadlowerratesoffiveadversepatientoutcomes:urinarytractinfections,pneumonia,shock,uppergastrointestinalbleeding,andlongerhospitalstay,86accordingtoastudybytheAgencyforHealthcareResearchandQuality.HospitalswithhighRNstaffinghadsurgicalpatientswithlowerratesoftwoadverseoutcomes:urinarytractinfectionsandfailuretorescue.87AdditionalstudieshaveshownthatincreasingtheproportionofRNs,inparticular,couldbethemostcost-effectivewayforhospitalstoreducetheriskofadverseoutcomes.
Patientsatisfactionreportsalsomayunveilproblemsinnursingsupply.AccordingtoHoagHospital’sCNORickMartin:“Thenursingshortagedoesnotgettheattentionitneedsfromthepublicnorfromthepoliticiansoreducationalsystems;itseemstobeundervalued.Thepublicisnotfeelingthepainyet;theywillstarttofeelitwhentheynoticethenursingshortageimpactonthemedical/surgicalunits,diversionsfromtheemergencydepartment,andsurgerycancellations.”
Optimizing talent and investment
Healthcareexecutiveswanttoknowhowtobecomemoreproductive,worksmarter,andensuresustainabilityandsuccessovertime.Aswehavedemonstrated,variousproblemswithinthehealthcareworkplacearecreatingsignificantdissatisfactionthatispushingnursesoutoftheworkforceprematurelyandharmingtheproductivityandcohesionofthosewhoremain.Recentnursingandhospitalturnoverdataillustratethemagnitudeofthisphenomenon.
Ametric,suchashumancapitalreturnoninvestmentthatfocusesonfinancialmeasures,isrelativelyilldefinedinhealthcarewheretheoutputrelatedtoreturnoninvestmentis,ideally,healthierpatients.Inrecentyears,theuseoffacility-andsystem-leveldashboardsandscorecardshasincreased.Progressiveorganizationsareensuringthatmetricssurroundinghumancapitalgetmeasured,getreported,andreceivehigh-levelattentionsimilartothetraditionalfinancialindicatorsthatfacilitieshavemeasuredforyears.Giventhatlaborcostsconsumeapproximately49%ofthetotalorganizationalcostsformosthospitals,andthatanestimated30%ofhospitalemployeesareregisterednurses,keymeasurementssurroundingthenursepopulationshouldbeadopted.8889
Themajorityofnurseturnoveroccursinthefirstyearsofservice(Figure20).VHA’sCNOGelinassecondsthisnotion:“Nursesareleavingjobsafteronly24to36months.They’resaying,‘ThisisnotwhatIbargainedfor.’Theproblemisthatmosthospitalsjustaren’tgreatplacestowork.”Thespreadforthismetricbetweenthebest-andworst-performingorganizationsislarge,indicatingsubstantialimprovementopportunities.Perhapsthisfindingisnotsurprising,butitdoesreinforcetheneedforinnovativeretentioneffortsfocused
Figure 20. Selected hospital turnover metrics
Metricname N 10th 25th Median 75th 90th
Overallnursevoluntaryseparationrate
22 5.5% 7.0% 8.4% 10.5% 17.1%
%nursevoluntaryturnover1styrofsvc
23 13.0% 20.8% 27.1% 34.3% 40.7%
%nursevoluntaryturnover1-3yrsofsvc
22 18.4% 21.0% 28.1% 32.8% 37.2%
Voluntaryseparationrate(healthcare)
54 7.5% 9.1% 10.7% 13.6% 17.6%
Source:PricewaterhouseCoopersSaratoga90
33 PricewaterhouseCoopers
onneweremployees,includingtakingstepstoensurethatappropriateorganizationalfitandhiringdecisionsaremadeinthefirstplace.
Nurseswhoquitcarrysignificantcoststotheirorganizations—coststhatmaybedifficulttofullyquantify.Acomprehensivecostestimatewouldincludethefollowing:
Recruiting,advertisingandplacement
Learningandeducation
Humanresourcescosts(newhires,recruitingagency,etc.)
Training
Additionalovertime/pressuresonremainingstaff
Agencycostsduringvacancy
Opportunitycosts(delaysinexpansion,diversions,etc.)
Lostteamcohesion/productivity
Quality
Thetotalcostrelatedtothelossofanursecanequatetoasmuchastwotimestheannualsalaryofthatnurse.91HRIestimatesthatreductioninturnovercansaveanillustrativehospitalupto$3.6millionannually.Basedonanaveragehospitalof350full-time-equivalentnurses,everypercentinincreasednurseturnovercostsanaveragehospitalabout$300,000annually(Figure21).
Figure 21. Cost of nurse turnover for low-performing hospitals
Hospitalnurseturnoverperformance
Lowest10%
Lowest25% Median Top25% Top10%
Nurseturnoverrate
17.1% 10.5% 8.4% 7% 5.5%
Annualcostofturnover
5.4M 3.3M 2.6M 2.2M 1.7M
Source:PricewaterhouseCoopers’HealthResearchInstitute92
•
•
•
•
•
•
•
•
•
Recommendations
Incentivize teamwork. Recognitionshouldbegiventotheimprovedoutcomesachievedwhenteamsareexperiencedandfamiliar,worktogethercollaborativelyandsharecommonincentivescenteredonefficiency,quality,andperformance.Entitiesshouldexaminetheirrewardstructurestoensurethattheincentivesarealignedtoallowforincreasedchancesofachievingthedesiredresults.Giventhefundamentalroleofphysicians,specificconsiderationshouldbegiventoaligningphysicianincentiveswithenterpriseincentivesthroughtheuseofvariouscollaborativemodels—includinggainsharing,co-management,andintegratedandjointventuremodels.93
Recognize the evolving incentives.Aspaymentisaffectedbypatientsatisfaction,anyproblemswithintheworkforcewillbecomenotonlymorevisiblebutalsofinanciallydetrimentaltotheunpreparedorganization.Inadditiontothefinancialincentives,participationinMedicare’spatientsatisfactioninitiativegivesahospitaltheopportunitytoidentifyareasofweaknessintermsofcaredeliveryandthestability,satisfaction,andcompetenceofitsworkforce.Aspartofthat,organizationsshouldbeproactiveincollecting—forbothnursesandphysicians—clinicaldatarelatedtoquality.Effectivelyimplementingpay-for-performancemodelscanresultinoverallprocessimprovement,betterqualityoutcomes,higherlevelsofpatientsatisfaction,andfewermedicalandadministrativeerrors.
Whatworks* 34
Connect quality outcomes to compensation.Organizationsshouldidentifyandmonitortheimpactoftheirnursingshortageonpatientoutcomesandimplementtheappropriatestrategies.Clinicaloutcomescanbeimprovedwithoptimalnursesupply—specifically,byincreasingtheproportionofRNs.Formallyrecognizingnursesasanintegralpartofthequalitychainandintegratingthenursingstaffinleadershipofqualityinitiativesaswellaslinkingcompensationandperformancecanyieldsynergy.Thoseorganizationsthatarerecognizedforoutstandingqualitywillattracthigh-performingstaffandphysicians.
Set benchmarks.Leading-edgeorganizationsaremeasuringtheirhumanresourcescapitalmetricsalongwiththeirfinancialmetrics,recognizingthecostsassociatedwithpoorandineffectivestaffingpractices.Considerationshouldbegiventotheevolvingimplicationsforcreditratingsaswellasthesignificantcosts(bothrealizedandopportunity)associatedwithpoorstaffingpractices.
Personal story. A higher calling
Forsome,healthcareistrulyacalling.RalphandDorisrunafamilypracticeasphysicianandheadnurse,respectively.Whiletheyviewhealthcareastheirministryofservice,theyareincreasinglyconcernedwiththeamountofadministrationandpaperwork.“Thereisasenseoffulfillmentwhentreatingpatientsandworkingwithpeople.Ilovethehumantouchandseekingsomewaytomakepatientssmile.”
The career
Tenure 30yearsasphysician/nurseteam
Educationfinancing Medicalschoolloans
%oftimeindirectpatientcare 75%
“Istartedasanengineerbutneverfeltitwastherightcareer,soIswitchedcollegesandcareersandstartedmedicalschool,”saysRalph.
Dorisadds,“Ilovebuildingthepatientinteractionandbuildingthepracticeastheheadnurse.”
The profession
“Thereisfartoomuchtimespentonpaperwork,documentation,andprotectionsfromlawsuits.Preauthorizationfrominsurersfordrugsandtestscreatesaburdenaswell.”RalphandDoris’sotherthoughtsabouttheprofession:
ManydoctorsintheregiondonottakeMedicaidbecauseofpoorreimbursement
Theyspendtoomuchtimeontasksthataren’treimbursedbyinsurersandthegovernment
•
•
35 PricewaterhouseCoopers
Conclusion
Despitetheamazingadvancesinmedicaldiagnosticandtherapeuticcapability,themodelfortheeducationandpracticeofnursesandphysicianshasnotchangedmuchinthelast50years.Thereisverylittletechnologyusedintheprocessofcare.ThemanagementrevolutionthathassweptoverAmericanbusinessandindustryduringthaterahas—toalargedegree—bypassedthehealthcareworkplaces.Healthcareorganizationsmustembracethemanyknowneffectivestrategiesforhelpingpeopleworkindividuallyandasteams.Thiscanbeachievedthroughsharedgovernance,establishedandtransparentperformancemetricsinkeyareas,incentivealignmentacrossteamswithgainsharingforall,andunifiedmissionwithoutfunctionalsilos.Thetoolsareavailablebutmustbeimplementedthroughfocusedleadershipthatcanlookbeyondday-to-daypressuresandtowardafuturevision.
Movingfromtoday’sworkforcemodeltothefuturewillbedisruptivetostaffandtheorganization;however,astheindustrychanges,ahealthsystemororganizationmustchangewithit(Figure22).
Figure 22. Transitioning from today’s workforce to tomorrow’s will be disruptive
Payment
Venue
Records
Treatment
Today’s clinicians were trainedfor this environment
Today’s students need to be trained to work in this environment
Volume based
Hospital based
Paper
One size fits all
Performance-based
Integrated, outpatient
Electronic
Personalized
1990 2000 2010 2020
Source:PricewaterhouseCoopers’HealthResearchInstitute94
When hospital executives surveyed by HRI were asked which situations would be most likely to “get their attention,” hospital CEOs ranked revenue shortfalls and decline or loss of profitability as first and second, respectively, while CMOs and CNOs chose accreditation jeopardized and bed closures due to staffing shortages as their top picks. There is clearly a significant disconnect between hospital CEOs and clinician executives around prioritization of organizational strategy and resources. Ultimately, if clinicians want to gain stature in the hospital and public policy hierarchy, they will need to convince CEOs and other decision-makers that medical workforce issues are crucial for our health system’s success. After all, this is an industry running on people power.
Whatworks* 36
Appendix
Commonpractice Bestpractice Leadingpractice
Standardshiftassignments(shiftsassignedbasedonasetoffactors)
Flexiblescheduling(flexibilityworkedintoschedulingtomeetspecifichospitalandpersonalneeds)
Web-basedshift-bidding(nursesabletorequestshiftsthroughonlineprograms)
Ignoreworkplaceergonomics(littlethoughtputintodesignofworkstations)
Correctergonomicdesign(facilityconveniences,suchasergonomicequipment,implementedtomakeworkenvironmentmorefunctionalfornurses)
Personalizedergonomics(conveniencesbeyondergonomicequipment;facilityconveniencesthatsupportdailyfunctions)
Top-downmanagement(traditional,low-staff-involvementmodel)
Staffinvolvement(stilltopdrivenbutmorestaffinvolvement)
Sharedgovernance(staffinvolvedindecision-makingprocess)
Non-merit-basedcompensation(job-specificcompensation)
Merit-basedcompensation(individualachievementtakenintoaccount)
Rewardsbasedonachievedresults(performancemetricssuchasqualityoutcomesandachievinggoalstakenintoaccount)
Toleranceofabuse(abuseofnursesbyphysicians)
Policyandprocedureinplaceandwellcommunicated
(issuesnotignored;policiesonabusewrittenandstaffmadeaware)
Decisiveexecutiveactiontakenwhennecessary(consistentenforcementofprocessestodealwithnegativebehaviors)
Continuousqualityimprovement(CQI)handledthroughseparatequalityimprovement(QI)unit
(nointegration;CQIoperatesasseparatesilo)
NurseinvolvementwithCQIinitiatives(nursesgettinginvolvedwithqualityimprovement)
Nurse-ledCQIinitiatives(clinicalstaffdrivingqualityinitiatives)
Longevitynotrewardedwithcompensation(norewardfortenure)
Seniorityrewardedwithcompensation(compensationincentivetostaywiththesameorganization)
Retirementplansstructuredtorewardlongtenure(plansdesignedtoincentivizestafftostaywiththeorganizationuntilretirement)
FragmentedITinitiativeswithinadequatechangemanagement(recognitionoftechnologybutnoprocesschange)
FragmentedITinitiativeswithadequatechangemanagement(recognitionthatunderlyingprocessesmustchangetoutilizetechnology)
FullyintegratedITdeploymentwithexcellentchangemanagement(fullrecognitionofprocesschangeandimprovement)
Appendix A. Retention enhancement practices
37 PricewaterhouseCoopers
B. Global migration of health professionals95
AsNewYorkTimescolumnistThomasFriedmanwroteinhisbest-sellingbook,wearelivingina“flatworld.”96Thefreeflowofcapitalandinformationislevelingtheglobalplayingfield.Similarly,theflowofpeopleisimpactingtheworldwidehealthcaremarketplaceinnewways.TheUnitedStates,theUnitedKingdom,Canada,andAustraliaarethelargestimportersofinternationalnursesandphysicians.Withinternationalmedicalgraduates(IMGs)makingup23%to28%oftheirphysicians,IMGshavebecomeanintegralcomponentoftheworkforceinthefourcountries.Language,cultural,andtraininggapscanmakethetransitiontoU.S.healthcaredifficult,butmanyU.S.hospitalsovercomethisthroughstructuredculturaltransitionprograms.
Whiletheinternationalmigrationofphysiciansandnursesisalong-standingaspectofglobalization,newconcernsarebeingraisedaboutthebraindrainonexportingcountrieswiththeirowntenuoushealthcaresystems.Whilethereissignificantmigrationamongthefourbiggestrecipientcountries(exceptthatout-migrationfromtheU.S.isvirtuallynil),thelargestpercentageofIMGsoriginatefromlower-incomecountries.FortheU.S.,60.2%ofIMGscomefromlower-incomecountries;fortheUnitedKingdom(UK),75.2%;forCanada(CA),43.4%;andforAustralia(AU),40%.
Thetop12sourcecountriesofIMGspracticinginUS/UK/CA/AUareIndia,thePhilippines,Pakistan,theUK,Egypt,China,SouthAfrica,Germany,Mexico,Ireland,SouthKorea,andNigeria.IndiaandPakistantogetheraccountformorethanhalfofthetotalIMGssuppliedbythetop12“exporters.”However,someofthesecountriesdon’thaveenoughclinicianstotreattheirownpopulations.Forexample,theWorldHealthOrganizationrecommendsaminimumdensityforphysiciansis20perevery100,000people,andfornurses,500perevery100,00097(Figures23and24).
Figure 23. RNs per 100,000 by host/source country
Hostcountries
RNs/100,000
Physicians/100,000
Lifeexpectancy(M/F)
Sourcecountries
RNs/100,000
Physicians/100,000
Lifeexpectancy(M/F)
Australia 941 247 78/83 SouthAfrica
472 77 47/49
UnitedKingdom
847 230 76/81 Philippines 418 58 65/72
NewZealand
841 237 77/82 Zimbabwe 129 16 37/34
Ireland 804 279 75/81 China 99 106
UnitedStates
782 256 75/80 Nigeria 66 28 45/46
Canada 741 214 78/83 India 45 60 61/63
Pakistan 34 74 62/63
Source:UnitedNationsDevelopmentProgramme98
Whatworks* 38
Figure 24. RNs per 100,000 by source country
0
200
400
600
800
1,000
Recommended density level
500 RNs per 100,000 people
Australia UK NewZealand
Ireland US Canada SouthAfrica
Philippines Zimbabwe China Nigeria India Pakistan
Source:UnitedNationsDevelopmentProgramme100
Migrantsarealso“pulled”todevelopedcountriesbyvariousattractionssuchasmodernmedicalenvironments,betterpay,career-advancementopportunities,physicalsafety,andpoliticalfreedom.Industrializednations,withamplemedicalinfrastructureandhigherpay,havebecomemagnetsforphysiciansandnursesfrompoorernations,leavingmanyoftheworkforcedonornationswithincreasingshortages.Forexample,29%ofGhana’sphysiciansareworkingabroad.Ghanalost382nursestoemigrationin1999,equaltothatyear’sentirenursingschooloutputofgraduates.Zimbabwereportedlylost2,000nursespermonthin2003.One-thirdofallZimbabweannursesareworkingabroad.InSouthAfrica,thenurse’sunionestimatesthat300nursespermonthemigrate.Oncepeoplemigratetoanearbycountry,theyarebetterpreparedandmorelikelytomoveevenfartheraway.Mostsub-SaharanAfricannationsareconsideredbyWHOtohaveacriticalshortageofhealthcarepersonnel.101
ThehealthcareprofessionalshortfallinAfricaisfurtheraggravatedbytheHIV/AIDSepidemic,creatinggreatclinicalneedwhilealsodiscouraginganddisablinghealthcareworkers.ForAfricaasawhole,HIV/AIDSwillbethecausein19%to53%(pervariousestimates)ofallpublicsectorhealthcareemployeedeaths.102
Anotherwayoflookingatthisisthroughtheuseofanemigrationfactor(thepercentageofsource-countryphysicianslosttoemigrationtoUS/UK/CA/AU.)Byregion,thehighestemigrationfactorisforsub-SaharanAfrica(13.9%),whichcanleastaffordthisdrain.ThenexthighestistheIndiansubcontinent,at10.7%,thentheCaribbeanat8.4%,followedbytheMiddleEastandNorthAfricaat5.2%.
Inaddition,manymiddle-incomecountrieswithgoodmedicaleducationsystems—suchasFiji,Jamaica,Mauritius,andthePhilippines—enrollstudentswiththeintenttoemigrateforjobopportunitiesincountriesoftheOrganizationforEconomicCooperationandDevelopment.TheRepublicofthePhilippineshasbecometheworld’slargestexporterofnursesandanticipatesremittancesfromthoseexpatriatesasaboosttotheeconomy.Anestimated85%(164,000)ofemployedFilipinonursesareworkingin46countries,primarilytheU.K.,SaudiArabia,Ireland,Singapore,andtheU.S.103Inaddition,Filipinodoctors,frustratedwiththeirdomesticprospects,areretrainingasnurses.Comparedwithmedicine,nursingisseenasafasterandeasierpathwaytoemigrationandawell-payingjob.Since2000,3,500Filipinodoctorshaveretrainedasnurses,andanother4,000Filipinodoctorsareinnursingschool.104
One of the basic concepts employed to understand the dynamics of nurse and physician migration is the “push/pull factor.”99 Source country conditions such as inadequate resources, poor pay, lack of safety, and political oppression may act to “push” professionals to emigrate. Once a shortage develops, a vicious cycle is created because those who are left are overworked and may want to leave as well.
39 PricewaterhouseCoopers
HealthResearchInstitute
Cater PatePartner,[email protected](703)918-1111
David Chin, M.D.Partner,[email protected](617)530-4381
Sandy [email protected](214)754-5434
Hindy [email protected](703)453-6161
Benjamin [email protected](214)754-5091
Paul [email protected](267)330-3460
Nicholas Korns, [email protected](860)241-7483
Jessica [email protected](267)330-3024
Ginger [email protected](865)769-2022
Shubha [email protected](678)419-1424
Kevin [email protected](720)931-7204
Health Research Institute Advisory team
Dianne Dismukes, R.N.Partner,[email protected](214)754-5170
Gerald McDougallPartner,[email protected](267)330-2468
Frances PennellPartner,[email protected](617)530-4780
Jack Rodgers, Ph.D.ManagingDirector,[email protected](202)414-1646
Deedie Root, Ph.D., R.N. ManagingDirector,[email protected](713)356-8532
Bill [email protected](678)419-1591
Janet [email protected](703)918-1408
Patricia Michaels, [email protected](314)206-8212
Nik [email protected](202)414-3866
Margaret [email protected](267)330-1379
Elizabeth Kaczmarek, [email protected](713)356-4107
Warren Skea, [email protected](214)754-5406
Linda Young, [email protected](813)222-5423
Deborah Allbach, [email protected](214)754-5481
Research Institute Contributors
HRIwouldalsoliketoacknowledgethefollowingparticipantsinthePwCThought-Wikiprogramandtheircontributions:
WilliamRosenberg,JeffreyShort,RyderSmith,MitchelHarris,JackieMazoway,KunbiOguneye,JonSouder,JudithCremeens,KristiKawamoto,JaniceFang,JulieEpstein,VanessaSam,andDanielCummins
Whatworks* 40
1MedicarePaymentAdvisoryCommission,ReporttotheCongress:MedicarePaymentPolicy,March2007,72.(RepresentsGraduateMedicalEducationandIndirectMedicalEducationexpenditurescombined.)
2VHAResearchSeries2002;7.TheBusinessCaseforWorkForceStability.
3Shepard,S.,“LaborPainsatTheMed:Last-MinuteDiversionsCreateHavocatOtherHospitals,”MemphisBusinessJournal,January19,2007.
4MedicarePaymentAdvisoryCommission,ReporttotheCongress:MedicarePaymentPolicy,March2007,57-58.
5ibid,54.
6AmericanHospitalAssociation,TheLewinGroup,TrendWatchChartbook2006:TrendsAffectingHospitalsandHealthSystems,March2006,chart5.6.
7PwCanalysisbasedoncompanywebsites,April,2007.
8HealthResourcesandServicesAdministration.TheRegisteredNursePopulation:Findingsfromthe2004NationalSampleSurveyofRegisteredNurses.II.TheRegisteredNursePopulation1980-2004.March2006.Accessed3/21/07athttp://www.bhpr.hrsa.gov/healthworkforce/rnsurvey04/.WhatIsBehindHRSA’sProjectedSupply,DemandandShortageofRegisteredNurses?II.NursingSupplyModel.September2004.Accessed3/21/07athttp://www.bhpr.hrsa.gov/healthworkforce/reports/nursing/rnbehindprojections/index.htm.Note:PastnumbersincludeRNpopulationwithalicensetopracticeintheU.S.ProjectednumbersincludethenumberoflicensedRNs.
9Auerbach,D.,Buerhaus,P.,andStaiger,D.,BetterLateThanNever:WorkforceSupplyImplicationsofLaterEntryintoNursing.HealthAffairs.2007;1:178-185.
10ibid
11ibid
12HealthResourcesandServicesAdministration(HRSA),What’sbehindHRSA’sProjectedSupply,Demand,andShortagesofRegisteredNurses?September2004,accessed4/2/07athttp://bhpr.hrsa.gov/healthworkforce/reports/nursing/rnbehindprojections/index.htm.
13ibid
14HealthResourcesandServicesAdministration.TheRegisteredNursePopulation:Findingsfromthe2004NationalSampleSurveyofRegisteredNurses.II.TheRegisteredNursePopulation1980-2004.March2006.Accessed4/12/07athttp://www.bhpr.hrsa.gov/healthworkforce/rnsurvey04/.Note:Public/CommunityHealthincludesschoolandoccupationalhealth.Othersincludepositionsininsuranceclaims/benefits,policy/planning/regulatory/licensing,correctionalfacilities,privateduty,andhome-basedself-employment.For2004,NursingEducationcollectivelyincludesRN,LPN/LVN,alliedhealth,medicalschool,andconsumereducationsettings.ThetotalnumbersofRNsacrossallsettingsofemploymentmaynotequalthetotalestimatednumbersofnursesduetoincompleteinformationprovidedbyrespondentsonsettingsandtotheeffectofrounding.
15AssociationofAmericanMedicalColleges,HelpWanted:MoreU.S.Doctors;ProjectionsIndicateAmericaWillFaceShortageofM.D.’sby2020.2006.
16AmericanHospitalAssociation,TheLewinGroup,TrendWatchChartbook2006:TrendsAffectingHospitalsandHealthSystems,March2006,Chart5.1.
17HealthResourcesandServicesAdministration(HRSA).PhysicianSupplyandDemand:Projectionsto2020.October2006.
18Cooper,R.,“WeighingtheEvidenceforExpandingPhysicianSupply.”AnnalsofInternalMedicine.141,no.9(November2,2004):708.
19Wennberg,J.,VariationinUseofMedicareServicesamongRegionsandSelectedAcademicMedicalCenters:IsMoreBetter?”TheCommonwealthFund,December2005.
20HealthResourcesandServicesAdministration.PhysicianSupplyandDemand:Projectionsto2020.October2006.Accessed3/20/07athttp://www.bhpr.hrsa.gov/healthworkforce/reports/physiciansupplydemand/default.htm.Note:HRSASupplyincludestotalactiveMDsandDOs.Physiciansaged75andolderareexcluded.HRSADemandincludespatient-careandnon-patient-carephysicians.30%IncreaseinEnrollmentbasedonAAMC’scallforenrollmentincreasebyyear2015.A30%enrollmentincreasein2015equatesto5,000additionalenrollments.Itisassumedthatall5,000additionalenrollmentswillgraduatefrommedicalschoolin2019andgoontobecomeactivephysicians.Assumingtheincreaseinenrollmentcontinuesin2016andalladditionalenrollmentsgraduateandgoontobecomeactivephysicians,supplywillincreasebyanother5,000physiciansin2020.
21Starfield,B.,Shi,L.,Grover,A.,Macinko,M.TheEffectsofSpecialistSupplyonPopulations’Health:AssessingtheEvidence.HealthAffairs.2005;W5:97-107.
22Goodman,D.,etal.End-of-LifeCareatAcademicMedicalCenters:ImplicationsforFutureWorkforceRequirements.HealthAffairs.2006;25(2):521-531.
23Aiken,L.,AcademyHealthBellagioConference:InternationalNurseMigration,July5-10,2005.UnitedStatesPresentations.accessed9/20/06athttp://www.academyhealth.org/international/nursemigration/presentations.htm.
24NationalCouncilofStateBoardsofNursing.NCLEXexaminationstatisticsfor2005.NCSBN2005.
25Mullan,F.,TheMetricsofthePhysicianBrainDrain.NewEnglandJournalofMedicine.2005;353:1810-1818.
26AssociationofAmericanMedicalColleges.HelpWanted:MoreU.S.Doctors;ProjectionsIndicateAmericaWillFaceShortageofM.D.sby2020.2006.
27AmericanBoardofPediatrics.“2004-2005WorkforceData”accessed12/20/06,athttps://www.abp.org/ABPWebSite/;“FactsaboutFamilyMedicine”accessed12/20/06,athttp://www.aafp.org/online/en/home/aboutus/specialty/facts.html; “InternalMedicineResidencyPrograms,”accessed12/20/06,athttp://www.abim.org/resources/trainim.shtm.
28AmericanAssociationofCollegesofNursing(2005data).PersonalcommunicationwithRobertRosseter,associateexecutivedirector.
29GelinasL.,BohlenC.,Tomorrow’sWorkForce:AStrategicApproach.VHAResearchSeries2002;1.
30AmericanHospitalAssociation.Chartbook:TrendsAffectingHospitalsandHealthSystems,April2007.Chapter5:Workforce.Accessed4/23/07athttp://www.aha.org/aha/research-and-trends/trendwatch/2007chartbook.html.
31ThePerfectStorm:AnRxforEffectiveNurseStaffing.AMNHealthcare.November1,2006.accessedviawww.amnhealthcare.com.
32AmericanAssociationofCollegesofNursing.“Re:MedicalWorkforceResearch.”E-mailtoJessicaShure.12Dec.2006.
Endnotes
41 PricewaterhouseCoopers
Endnotes
Note:A“qualifiedapplicant”isonewhomeetsallprogramentryrequirementsandwhotypicallyhasahighenoughundergraduateGPA,goodscoresonentranceexaminationssuchastheGMAT,andacompetitiveapplication/essay.Everyschoolisdifferent,soapplicationrequirementsdovary.TheAmericanAssociationofCritical-CareNursesasksschoolstosupplydataonthenumberofqualifiedapplicationsreceivedatnursingschoolsminusthenumberofapplicantsaccepted.
33InstituteofWomen’sPolicyResearch.NewStudyLinksNurseShortagetoNursePay.March2006.AccessedDecember2006athttp://www.iwpr.org/pdf/PressRelease2_ 8_06.pdf.Note:OriginaldatastatedasMedianWeeklyEarnings.PwCcalculatedtheMedianAnnualEarningsbymultiplyingtheweeklyearningsby52.
34AssociationofAmericanMedicalColleges.HelpWanted:MoreU.S.Doctors;ProjectionsIndicateAmericaWillFaceShortageofM.D.sby2020.2006.
35AssociationofAmericanMedicalColleges.AAMCStatementonthePhysicianWorkforce.June2006.
36SummaryReportoftheGraduateMedicalEducationNationalAdvisoryCommittee,September30,1980.DHHSPublicationno.(HRA)81-651.Washington,DC:U.S.DepartmentofHealthandHumanServices;1980.accessedviahttp://www.acponline.org/hpp/pospaper/health.htmon4/23/07.
37BureauofHealthProfessions.NationalCenterforHealthWorkforceAnalysis:U.S.HealthWorkforcePersonnelFactbook.Table102.NumberofActivePhysicians(MDs)andPhysician-to-PopulationRatiosbySpecialty,SelectedYears1970-2000.Accessed3/30/07athttp://bhpr.hrsa.gov/healthworkforce/reports/factbook.htm.
38AssociationofAmericanMedicalColleges.HelpWanted:MoreU.S.Doctors.Accessed3/27/07athttp://www.aamc.org/workforce/.
39ibid
40Blank,A.,OpeningNewMedicalSchoolRequiresPatience,Persistence.AAMCReporter:March2005.accessed4/24/07viahttp://www.aamc.org/newsroom/reporter/march05/newschools.htm.
41AssociationofAmericanMedicalColleges.Facts-Applicants,MatriculantsandGraduates.MatriculantsbyState.October2006.Accessed2/23/07athttp://www.aamc.org/data/facts/start.htm.
NewFacilities,NewPartnershipsMedicalEducationExpands.February2004.Accessed2/23/07athttp://www.aamc.org/newsroom/reporter/feb04/newfacilities.htm.
42AssociationofAmericanMedicalColleges.AAMCStatementonthePhysicianWorkforce.June2006.
43TheNewYorkCenterforHealthWorkforceStudies.TheUnitedStatesHealthWorkforceProfile.October2006.
44HealthResourcesandServicesAdministration(HRSA)..HealthProfessionalShortageAreas.Accessed4/24/07viahttp://bhpr.hrsa.gov/shortage.
45TheNewYorkCenterforHealthWorkforceStudies.TheUnitedStatesHealthWorkforceProfile.October2006.
46AmericanAcademyofFamilyPhysicians.2002PrimaryCareHPSAs.2007.Accessed4/26/07athttp://www.graham-center.org/x815.xml.
47Bodenheimer,T.,PrimaryCare—WillItSurvive?NewEnglandJournalofMedicine.2006;355:861-864.
48ibid
49AmericanAcademyofFamilyPhysicians.“AAFPAdoptsNewPhysicianWorkforcePolicy.”September28,2006.Accessed4/24/07athttp://www.aafp.org/online/en/home/press/aafpnewsreleases/200609pr/20060928workforcepolicy.html.
50AmericanAssociationofMedicalColleges.MedicalStudentEducation:Cost,Debt,andResidentStipendFacts.October2006.
51ibid
52AmericanMedicalAssociation.2003ReportoftheAmericanMedicalAssociation—MedicalStudentSectionTaskForceonMedicalStudentDebt.Accessedviahttp://www.ama-assn.org/ama1/pub/upload/mm/15/debt_report.pdf.
53AmericanAssociationofMedicalColleges.2006MedicalSchoolGraduationQuestionnaire.
54AssociationofAmericanMedicalColleges.MedicalSchoolGraduationQuestionnaire.AverageTotalEducationalDebtofAllStudents.Accessedathttp://www.aamc.org/data/gq/allschoolsreports/start.htm.BureauofLaborStatistics.NationalOccupationalEmploymentandWageEstimates.HealthcarePractitionerandTechnicalOccupations.Accessedathttp://www.bls.gov/OES/.
InflationCalculator.Accessedathttp://146.142.4.24/cgi-bin/cpicalc.pl. SallieMae.StudentLoanInterestRatesandFees.Accessedathttp://www.salliemae.com/get_student_loan/apply_student_loan/interest_rates_fees/#Stafford. U.S.GovernmentSecurities/TreasuryBills.Accessedathttp://www.federalreserve.gov/releases/h15/data/Business_day/H15_TB_M3.txt. Note:PwCanalysisofthemonthlydebtobligationinvolvedadjustingthedebtamountforinflation,performingafinancialcalculationusingtheStaffordLoaninterestrate,andassuminga10-yearpayperiod,withpaymentsoccurringmonthly.PwCanalysisofmonthlyincomeinvolvedtakingaweightedaverageofwagesacrossphysicianspecialties,adjustingforinflation,anddividingby12.
55InstituteforWomen’sPolicyResearch.SolvingtheNursingShortagethroughHigherWages.2006.
56HealthResourcesandServicesAdministration.TheRegisteredNursePopulation:Findingsfromthe2004NationalSampleSurveyofRegisteredNurses.Chart9.Actualand‘Real’EarningsforRegisteredNurses,1980to2004.March2006.Accessed3/15/07athttp://www.bhpr.hrsa.gov/healthworkforce/rnsurvey04/.Note:Onlythosewhoprovidedearningsinformationareincludedinthecalculationsusedforthischart.
57KellermannA.,CrisisintheEmergencyDepartment.NewEnglandJournalofMedicine.2006;355:1300-1303.
58PricewaterhouseCoopers’HealthResearchInstituteSurvey.
59Green,S,Pone,J,Cahill,C.,ReducingStaffingAgencyDependencyandImprovingReturnonInvestment.NurseLeader.October2004:42-46.
60PricewaterhouseCoopers’HealthResearchInstituteSurvey.
61ibid
62CitedinGelinasL.,BohlenC.,Tomorrow’sWorkForce:AStrategicApproach.VHAResearchSeries2002;1.
63ibid
64ibid
65ibid
Whatworks* 42
Endnotes
66NationalLeagueforNursing.NursingDataReview.AcademicYear2004/05.NationalCouncilofStateBoardsofNursing.NurseLicensureandNCLEXExaminationStatistics.2004.Accessed4/12/07athttps://www.ncsbn.org/462.htm.Note:Numbersarefromthe2003/04academicyear.
67PricewaterhouseCoopers’HealthResearchInstituteSurvey.
68PricewaterhouseCoopers’HealthResearchInstitute.
69“Tenn.toEncourageNursingInstructorsthroughLoanForgiveness,”Tennessean(Nashville,TN),January23,2007,http://tennessean.com/apps/pbcs.dll/article?AID=/20070123/NEWS07/70123011/, accessedonJanuary30,2007).
70NationalCouncilofStateBoardsofNursing,accessedviahttps://www.ncsbn.org/nlc.htm on4/16/07.
71NorrisT,etal.,RegionalSolutionstothePhysicianWorkforceShortage:TheWWAMIExperience.AcademicMedicine2006;81:857-862.
72PerWebsiteaccessedon4/25/07,http://www.novahealthforce.com/about/index.html.
73PricewaterhouseCoopers,TheHealthCareWorkforceShortage:ExecutiveSummary,PreparedfortheNorthernVirginiaHealthCareWorkforceAlliance,January2005,http://www.novahealthworkforce.org,accessedon2/2/07.
74HealthResourcesandServicesAdministration(HRSA).TheRegisteredNursePopulation:FindingsfromtheMarch2004NationalSampleSurveyofRegisteredNurses.
75AmericanAssociationofMedicalColleges.2006MedicalSchoolGraduationQuestionnaire.
76BureauofLaborStatistics.November2004EmploymentandWageEstimates.HealthcarePractitionerandTechnicalOccupations.November2005.Accessed3/29/07athttp://www.bls.gov/oes/2004/november/oes_29He.htm.AmericanAcademyofNursePractitioners.DocumentationofNursePractitionerCost-Effectiveness.2004.Accessed3/29/07athttp://www.aanp.org/NR/rdonlyres/.
77Whitcomb,M.,TheShortageofPhysiciansandtheFutureRoleofNurses.AcademicMedicine2006;81:779-780.
78Daniel,L,etal.E-BiddingandHospitalAgencyUsage.JournalofNursingAdministration.2006;4:173-176.
79Davis,A,etal.,ImplementingaBiddingSystemforFillingOpenShifts.NurseLeader.August2004:46-49.
80Green,S,Pone,J,Cahill,C.,ReducingStaffingAgencyDependencyandImprovingReturnonInvestment.NurseLeader.October2004:42-46.
81Daniel,L.,E-BiddingandHospitalAgencyUsage.JournalofNursingAdministration.2006;4:173-176.
82Green,S,etal.,ReducingStaffingAgencyDependencyandImprovingReturnonInvestment.NurseLeader.October2004:42-46.
83AmericanNursesCredentialingCenter,accessedvia http://www.nursingworld.org/ancc/magnet/index.html on 4/19/07.
84AmericanNursesCredentialingCenter(asubsidiaryoftheANA).BenefitsofbecomingaMagnet-DesignatedFacility.ANCC2006.Accessed1/4/07athttp://www.nursingworld.org/ancc/magnet/benes.html.
85VHAResearchSeries2002;7.TheBusinessCaseforWorkForceStability.
86AgencyforHealthcareResearchandQuality.HospitalNurseStaffingandQualityofCare.ResearchinAction:Issue14.March2004.
87ibid
88PricewaterhouseCoopers’Saratoga,2006/2007HumanCapitalEffectivenessReport.
89U.S.DepartmentofLabor,BureauofLaborStatistics,CareerGuidetoIndustries,HealthCareGuide,http://www.bls.gov/oco/cg/cgs035.htm,(accessed2/16/2007).
90PricewaterhouseCoopersSaratoga.
91Atencio,B.,Cohen,J.,Gorenberg,B.NurseRetention:IsitWorthIt?NursingEconomics.Volume21,Number6,viahttp://www.medscape.com/viewarticle/465918,accessed3/15/2007.
92PricewaterhouseCoopers’HealthResearchInstituteanalysisbasedonahospitalwith350NurseFTEs,April,2007.
93Booth,J.,Hickman,B.,Matson,B.,“WorkingTogether:PhysiciansandHospitalsPartneringforQualityImprovement,”TheQualityConundrum,PricewaterhouseCoopersHealthResearchInstitute,2007.
94PricewaterhouseCoopers’HealthResearchInstitute.
95Mullan,F.,TheMetricsofthePhysicianBrainDrain.NewEnglandJournalofMedicine.2005;353:1810-1818.
96Friedman,ThomasL.,TheWorldIsFlat:ABriefHistoryoftheTwenty-firstCentury.NewYork:Farrar,Straus,andGiroux,2006.
97WorldHealthOrganization.TheWorldHealthReport2006—WorkingTogetherforHealth.
98UnitedNationsDevelopmentProgramme.HumanDevelopmentReport2006.Physicians(per100,000people).2006.Accessed4/17/07athttp://hdr.undp.org/hdr2006/statistics/indicators/58.html.
wwWorldHealthOrganization.Countries.Countries.2007.Accessed4/17/07athttp://www.who.int/countries/en/.
wwAikenL,BuchanJ,SochalskiJ,etal.TrendsinInternationalNurseMigration.HealthAffairs2004;23:69-77.
wwAdkoli,BV.MigrationofHealthWorkers:PerspectivesfromBangladesh,India,Nepal,PakistanandSriLanka.RegionalHealthForum2006;10:49-58.
99Kingma,M.,NursesontheMove:MigrationandtheGlobalHealthCareEconomy.IthacaandLondon:CornellUniversityPress,2006.
100UnitedNationsDevelopmentProgramme.HumanDevelopmentReport2006.Physicians(per100,000people).2006.Accessed4/17/07athttp://hdr.undp.org/hdr2006/statistics/indicators/58.html.
wwWorldHealthOrganization.Countries.Countries.2007.Accessed4/17/07athttp://www.who.int/countries/en/.
wwAikenL,BuchanJ,SochalskiJ,etal.TrendsinInternationalNurseMigration.HealthAffairs2004;23:69-77.
wwAdkoli,BV.MigrationofHealthWorkers:PerspectivesfromBangladesh,India,Nepal,PakistanandSriLanka.RegionalHealthForum2006;10:49-58.
101WorldHealthOrganization:CountriesProfilesaccessed12/21/06,athttp://www.who.int/en/.
102ibid
103AcademyHealthBellagioConference:InternationalNurseMigration,July5-10,2005.Presentations(12)accessed9/20/06,athttp://www.academyhealth.org/international/nursemigration/presentations.htm.
104AcademyHealth2006HealthinForeignPolicyForum,2/8/06.MigrationandtheGlobalShortageofHealthcareProfessionals(transcripts)accessed9/20/06,athttp://kaisernetwork.org/health_cast/hcast_index.cfm?display=detailandhc=1622.
About PricewaterhouseCoopers
Committed to the transformation of healthcare through innovation, collaboration and thought leadership, PricewaterhouseCoopers Health Industries Group offers industry and technical expertise across all health-related industries, including providers and payers, health sciences, biotech/medical devices, pharmaceutical and employer practices.
The firms of the PricewaterhouseCoopers global network provide industry-focused assurance, tax and advisory services to build public trust and enhance value for clients and their stakeholders. PricewaterhouseCoopers has aligned its professional service offerings around the future direction of the health system. By applying broad understanding of how individual, specialized sectors work together to drive the performance of the overall health system, the Health Industries Group is positioned to help clients, industry and governments address changing market forces of globalization, consumerism, consolidation and expansion, regulation, technology, workforce and margin compression.
The firms of the PricewaterhouseCoopers global network (www.pwc.com) provide industry-focused assurance, tax and advisory services to build public trust and enhance value for clients and their stakeholders. More than 130,000 people in 148 countries across our network share their thinking, experience and solutions to develop fresh perspectives and practical advice.
Health Research Institute
PricewaterhouseCoopers Health Research Institute provides new intelligence, perspectives, and analysis on trends affecting all health-related industries, including healthcare providers, pharmaceuticals, health and life sciences, and payers. The Institute helps executive decision-makers and stakeholder navigate change through a process of fact-based research and collaborative exchange that draws on a network of more than 3,000 professional with day-to-day experience in the health industries. The Institute is part of PricewaterhouseCoopers larger initiative for the health-related industries that brings together expertise and allows collaboration across all sectors in the health continuum.
www.pwc.com/healthindustrieswww.pwc.com/hri
© 2007 PricewaterhouseCoopers. All rights reserved. “PricewaterhouseCoopers” refers to PricewaterhouseCoopers LLP or, as the context requires, PricewaterhouseCoopers global network or other member firms of the network, each of which is a separate and independent legal entity. BS 07-0718 0607 JF
PricewaterhouseCoopers shall not be liable to any other user of this report or to any other person or entity for any inaccuracy of this information or any errors or omissions in its content, regardless of the cause of such inaccuracy, error, or omission. Furthermore, in no event shall PricewaterhouseCoopers be liable for consequential, incidental, or punitive damages to any person or entity for any matter relating to this information. This report is provided for informational purposes only and does not constitute the provision of tax, accounting, legal, or other professional advice.
This document was not intended or written to be used, and it cannot be used, for the purpose of avoiding U.S. Federal, state or local tax penalties.