Where has all the staff gone?

Strategies to recruit and retain quality staff

Recruiting and retaining quality staff is a national issue for all healthcare organizations, and transplant programs are also affected by this crisis. Transplant administrators are faced with increased regulatory burdens, reduced reimbursement, increased competition for uniquely qualified staff, and rising healthcare costs. These factors negatively affect transplant programs that try to ensure the infrastructure exists to provide quality care. Human resources management is a key component to transplant administration. In todays environment, administrators need to adopt long-term strategic practices to recruit and retain quality staff. Maintaining adequate staffing levels means thinking out of the box and looking at human resources management at all levels of skill mix including physician extenders that can perform the transplant coordinator role. Investing in the future development of staff can attract quality professionals to the field of transplantation for years to come. (Progress in Transplantation. 2007;17:89-93)

Helen M. Hauff, RN, MBA,

CCTC, CPTC
Recanati/Miller Transplantation Institute and Dialysis, Mount Sinai Medical Center, New York, NY To purchase electronic or print reprints, contact: The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656 Phone (800) 809-2273 (ext 532) or (949) 448-7370 (ext 532) Fax (949) 362-2049 E-mail reprints@aacn.org

uman resources management for transplant centers has become challenging in the era of increasing healthcare costs, reduced reimbursement, staffing shortages, and increased regulatory effect. Transplant centers have to rethink their approach to both recruitment and retention as well as to developing creative plans to attract the diverse interdisciplinary skill mix needed to support a transplant program and at the same time ensure quality care for patients. Many of the personnel roles required for a transplant center are clearly defined in either or both Centers for Medicare & Medicaid Services (CMS) regulations and United Network for Organ Sharing (UNOS) policy. Although the roles are defined, the actual staffing levels are not. Interestingly, there is no requirement for a transplant center to have a transplant administrator as a member of the team. The role of the transplant surgeon, transplant physician, transplant coordinator, social worker, pharmacist, nutritionist, and financial coordinator are major components of the requirements for any program. Other professionals such as transplant administrators, data coordinators, in-patient transplant nurses, preservationists, case managers, and adjunct physician specialists in infectious diseases, anesthesiology, cardiology, endocrine, and palliative care are also key to the program. Recruiting and retaining the right talent is one part of the equation. Developing the team collaboration through organizational development, professional devel-

opment, infrastructure, and culture also plays a major role in attracting and retaining the right staff at all levels. Human capital and the related intellectual capital are the most valuable resources of any program. However, according to national data, the focus will need to be on recruitment and certainly retention in the coming years. The United States is in the midst of an acute nursing shortage that will not be resolved anytime soon as more and more nurses choose to leave the profession and the number entering practice has fallen dramatically. 1 Both transplant physicians and specialty practice physicians are also in short supply and both are needed to support transplant programs and care for patients with complicated medical conditions. Successfully recruiting a transplant hepatologist or transplant cardiologist may feel similar to winning the lottery in todays transplant healthcare recruitment market. Nutritionists have also become in short supply as schools in some states are now required to have a nutritionist on staff, giving nutritionists more choice for employment opportunities. Social workers equally have an increased choice of career paths. Twenty-one percent of pharmacist positions across the United States are unfilled.2 Some of the void has been filled in recent years by international recruiting. However, this too is not without its own issues in the post-9/11 era of immigration difficulties and delayed visa issuance. The current healthcare market is complicated and fiscal management is becoming more complicated.

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Hauff Healthcare inflation rose 7% in 2004 and is expected to continue to rise,3 nursing salaries are predicted to increase 22% over the next decade, fringe benefits for employers has already increased 12%, and premiums for healthcare insurance rose 15% in 2003.3 The total cost of healthcare in the United States has increased to 16% of gross domestic product and is projected to increase to 20% by 2015.4 Reimbursement for professional fees is expected to decrease by 8.5% to 9.17%.4 Hospital reimbursement is projected to decrease by 1.2% for inpatient surgical transplant reimbursement moving to full cost reimbursement by 2009.5 Programs are facing an acute staffing shortage; in addition, they have to increase salaries to attract the right staff in an era of reduced reimbursement and increased operating costs that cut into the bottom line. From a human resources perspective, transplant centers need to become strategic in their approach to staffing and plan beyond the immediate need and develop programs that will support future staffing needs. Nursing Shortage Nursing has been the focus of much debate in recent years as the shortage worsened and recruitment has become more difficult. Recruitment costs per nurse have been estimated to be more than $100 000.6 In addition, the supply of nurses needs to increase by 9% to keep up with demand.7 For transplant centers, recruiting an experienced transplant coordinator with CCTC certification is a goal that is rarely achieved and most transplant coordinators are not certified. The expectation under the transplant center redesign from CMS is that every transplant program should have a certified coordinator. This mandate, although supported by the transplant coordinator community, will be difficult to achieve. Overall, the American Association of Colleges of Nursing has predicted a continual decrease in nursing of 4% to 2010.8 Some centers have shifted toward a nurse practitioner (NP) model of care because the NP scope of practice suits the autonomous role of the transplant coordinator. NPs also have a higher salary expense than regular registered nurses. The benefit of being able to bill for NP services may offset this cost, although rarely would an NP be able to cover base salary with receipts. The extended role has also been beneficial for physicians; in practices where physician vacancies exist, NPs have been able to provide high-quality care for transplant patients. Physician assistants (PAs) are often overlooked in the role of physician extenders for transplant centers and in the role of transplant coordinators. The classic role of the PA is specifically assisting the surgeon in the operating room or supporting the surgeons daily practice. Many PAs also work in the medical field and are beginning to find a niche in transplantation outside of the operating room. As nurses have become a scarce commodity, the PA has stepped up to fill the role of a transplant coordinator in some centers. Some PA programs rotate through transplant programs and centers have been able to groom the PA for the transplant coordinator role. Throughout the PA clinical training an element of on-call exists and PAs therefore adjust to transplant on-call situations quickly compared to nurses who rarely experience on-call in their training. The salary expense associated with hiring PAs can also in some areas be much less than that of hiring NPs. Where transplant coordinator vacancies do exist, some centers have opted to increase the support staff for the transplant coordinator, who can then delegate nonnursing transplant duties and focus on the nursing issues for the patients. Medical assistants have been trained to not only assist in the outpatient centers, but to work closely with the nurse coordinator filling medical office duties such as calling in prescriptions and obtaining precertifications for tests. They complement the coordinator assistant who also performs all of the office support for the transplant coordinator. This gives the transplant coordinator the opportunity to focus on clinical issues. In areas where vacancies have been left open, the void can be filled by this level of support staff. The role of licensed practical nurses (LPNs) has not received much attention in transplantation and these nurses have not been used as much as they could be. However, there is also a shortage LPNs.8 In addition, as hospitals work toward Magnet status, the need for nurses with bachelors of science degrees increases and the role of the LPN diminishes. What really needs to be addressed in this area is the workload for each coordinator. An acuity-based model needs to be developed to truly measure each nurses workload. Staffing surveys exist at the University Healthcare Consortium and UNOS; however, neither assesses patient acuity that would assist administrators in determining the true staffing levels required for a transplant program. Further work needs to include an assessment of effective skill mix for transplant centers. Some research has looked at the impact of on-call and staffing requirements for kidney programs, but no comprehensive quantitative analysis exists.9,10 When the transplant coordinator staff becomes overwhelmed, administrators often hear an immediate request for another nurse, when in reality additional support staff may be the answer. The strategic view of this issue must be to develop programs that will attract and retain staff. Partnering with schools of nursing to offer a transplant clinical rotation is one way to achieve this. Also, developing a 2-year postgraduate course for nurses with bachelors of science degrees has also helped increase staff and reduce retention. The 2-year program

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Where has all the staff gone? has clinical rotations to the inpatient unit and to the transplant program with protected time for lectures, conferences, and grand rounds. Depending on the clinical rotation schedule, large programs can support 2 to 4 nurses at any one time as they work through each area. The program is usually followed by a commitment from the nurse to stay 1 to 2 years after training within the transplant program. A usual expectation of such a program is for the nurse to complete the clinical certification for transplant coordinator examination at the end of the program. For programs expected to grow over 2 to 5 years, this is a good way to prepare for the future staffing needs. Physician Recruitment and Retention Physician recruitment has proven difficult in recent years, especially recruitment of surgeons. The number of transplant specialists is diminishing, although exact numbers are not recorded, and the national shortage of physicians is increasing.11 Medical schools also may need to increase enrollment by as much at 30% by 2010 to keep up with demand.11 This shortage also means an increase in market value of transplant faculty. It is not uncommon for transplant centers to structure compensation packets that include protected time for academic activities in order to attract faculty who also have the option of being successful in private practice or industry. The conflict for physicians is that much of their time is spent on nonbillable activities such as recipient reviews, postclinic reviews, pathology meetings, and general academic meetings. For centers where the expectation that faculty should cover their own salary through their billings and collections, this may be impossible to achieve in transplantation because 100% of the time is not spent on billable activities. Therefore, some hospitals may choose to partially support the salaries of the faculty for this reason as well as compensating for hospital clinic activities. Protected academic, teaching, and administrative time are components of a transplant physicians life. Again, reduced reimbursement and increased costs and increasing malpractice costs all cause centers to question how many surgeons and physicians are really needed and at what price. Adequate physician staffing levels for transplant centers is also of concern as well as competence and credentialing. Many physicians are recruited from abroad, especially at the fellowship level.11 One quarter of residency positions are currently filled by foreign medical school graduates.11 These physicians typically enter the United States on a J-1 training visa that can be issued for 3 years and then extended for a 3-year period. The J-1 visa has a 2-year home residency requirement, that is, at the end of the visa period the physician must return home for 2 years before reentering the United States to work. Centers try to retain their fellows to curb the physician shortage, but many are unsuccessful because of the home residency requirement. As a training visa, the J-1 visa does not allow the holder to take a faculty position; for this purpose, an H-1B visa is required, and one can only convert from a J-1 visa to an H-1B under the annual state waiver program, which limits the numbers of H-1B visas issued under these circumstances. With visa issues and the need for applicants to have US Medical Licensing Examination I, II, and III; have state licenses; and be cleared through Federation Credentials Verification Service, even the recruitment of fellows needs to be done a couple of years in advance of the start date. Given the visa restrictions and the compensation issues, attracting faculty to a center can be difficult. From a strategic perspective, the best option is to develop a fellowship-training program and endeavor to retain the services of the faculty members once they graduate. The development of ones own staff may be the best option. One area constantly neglected by all programs is the need for succession planning. Transplant programs often have a senior program director and a number of younger faculty members with no thought to the future succession of the program. Mentoring, coaching, and development of leadership have to occur with faculty if the long-term survival of the transplant program is to be protected. Furthermore, physicians can benefit from a potential career ladder. The retention of physicians highly depends on their professional success and the collaborative effort found at the transplant center. Physicians value compensation and incentives as well as academic potential within a highly successful program. Allowing development and professional growth for faculty is an area of medicine also often neglected and institutions are beginning to recognize the value of academic career development within their institutions to retain and attract staff. Compensation for physicians remains a controversial issue as centers try to contain costs and better understand the components of physicians compensation. The Medical Group Management Association publishes a guide to physicians salaries and this analysis is becoming a benchmark in setting transplant surgeons salaries. However, even with this management tool, one major component of the equation is missing: competition and market value of specialty physicians. Recruitment: The Personal Touch Many centers rely on the human resources department to meet their staffing needs. However, the administrator or senior coordinator also should contact potential employees about transplantation, for example, by sending letters to specialty members of organizations such NATCOThe Organization

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Hauff for Transplant Professionals and the American Association of Colleges of Nursing. Advertising on the UNOS Web site as well as other specialty organization Web sites is another option. Occasionally, centers may use professional headhunters to recruit staff for higherlevel management positions that are paid on contingency. Listservs and general Web sites have also become good vehicles for advertising positions. Recognizing the potential employment pool for a given institution is key when developing the right marketing strategy for recruitment, which will vary depending on the position that is vacant and how the program chooses to advertise and market itself. Physician recruitment through advertisements in specialty journals can be effective. However, personal phone calls from chairman to chairman or directly to the potential recruit is the most effective recruitment strategy. Centers tend to approach this process blindly; instead, looking at all the centers with training programs and contacting those individuals due to complete a fellowship about a year ahead of time may have better results. Just as transplant centers focus on the value of the referring physician, centers need to focus on the value of interpersonal relationships between faculty at different centers. Transplant conferences have become a recruiters dream. Attendee lists of any conference are an invaluable tool for a recruiter or transplant administrator. Competition Competition has become a major component of human resources management. As human capital becomes scarce and demand for specialty skills increases, salaries increase. Driving the salaries even higher is competition as centers compete for the same staff. The pool of staff has become fixed and it is not uncommon for staff to move from center to center, wherever the best compensation package can be found, especially in areas where transplant centers are located close to each other. Healthcare has rarely seen such a demand for staff as it is experiencing now. With increased competition comes increased staff turnover, which drives up costs associated with rehiring, retraining, and vacancy substitution. Generation X While human resources management has focused on the nursing shortage, recruitment and retention issues, and the retiring baby boomers, Generation X has become a reality in the workplace and these workers bring different attitudes to the workplace. This generation has grown up in the information age, in an era of economic prosperity, often highly independent and from single parent families.12 They are not interested in career progression or long-term relationships and will change jobs rapidly as the situation suits them. The contrast between baby-boomers and generation X has been well researched. Generation X workers demand a life and a job that are convenient to their chosen life.12 Therefore, Generation X workers often change jobs and are highly difficult to retain in one position; they need constant attention and help to grow professionally, and they need to be constantly challenged at work. Conclusion Human resources management in all areas of healthcare is difficult. However, a specialty service such as transplantation has the following challenges ahead to maintain adequate staffing levels: Real quantitative research is needed to accurately assess the actual staffing needs of transplant centers. Many tools exist to measure the numbers of full-time equivalents needed for intensive care units, even outpatient centers, but no tool exists that focuses solely on the transplant center. Staffing has been acutely affected by the nursing shortage. Centers need to be creative in analyzing their skill mix needs in order to maintain adequate patient care and develop training programs that look beyond the immediate staffing need. Expanding the role of the transplant coordinator to include PAs may be an option for some centers. Investment in training programs is one solution for both physician and nurse recruitment and retention. A comprehensive review needs to be done on the impact of all of the regulatory burdens now placed on transplant centers. The Joint Commission on Accreditation of Healthcare Organizations, Health Resources and Services Administration, CMS, state departments of health, and UNOS all have placed staffing requirements on transplant centers. All come at a price and if staffing levels are to be mandated, attention must be placed on the funding of such a mandate. Once centers experience negative contribution margins, institutions will be faced with the decision of determining whether transplant services should be offered at all given the rising cost of salary expenses. Good human resources management can decrease these costs by focusing on staff retention, reducing turnover, and ensuring professional growth for staff.
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/newscomments/news/Feb2006/HealthCosts.asp. Accessed October 22, 2006. American Society of Transplant Surgeons. 2007 Inpatient Prospective Payment Rule Analysis. Available at: www.asts.org /Tools/News.aspx?content_id=37. Accessed October 22, 2006. Kosel KC, Olivio T. The Business Case for Workplace Stability. Irving, Tex: VHA; 2002. Health Resources and Services Administration. Assessing the Adequacy of Future Supply. Available at: www.bhpr.hrsa.gov /healthworkforce/reports/behindrnprojections/4.htm. Accessed October 22, 2006. Health Resources and Services Administration. Nursing Supply Model. Available at: www.bhpr.hrsa.gov/healthworkforce /reports/behindrnprojections/4.htm. Accessed October 22, 2006. 9. Smithers F. The pattern and effect of on-call work in transplant co-ordinators in the United Kingdom. Int J Nurs Stud. 1995;32:469-483. 10. Saunders RN, Elwell R, Murphy GJ, Horsburgh T, Carr SJ, Nicholson ML. Workload generated by a living donor programme for renal transplantation. Nephrol Dial Transplant. 2000;15:1667-1672. 11. Salsberg E. Responding to Physician Shortage. Available at: www.physiciansnews.com/cover/406.html. Accessed October 22, 2006. 12. Cordeniz JA. Recruitment, retention, and management of generation X: a focus on nursing professionals. J Healthc Manage. 2002;47:237-249.

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