What’s a Nurse Manager do all day?

Besides eat peanut M&Ms and tell people what they're doing wrong...

This is a long one for this month. But you’re taking a trip through my brain, buckle up and enjoy the ride!

I decided to write this for a few reasons. The first, I often get this posed as a skeptical question when talking to people unfamiliar with health care institutions, and it’s been a struggle to explain all this. I think other people in health care struggle with this too, we tend to downplay what we do, assign a lot of value to teamwork more so than our own individual efforts. Whether it is primary care, specialty care, hospitals or clinics, we all rely on each member of the team to be involved in the process and contribute toward caring for the patients.

The second, I’ve spoken with a lot of nurses and nurse managers that are thinking of leaving or have left out of frustration. They are finding similar frustrations when trying to move out or up into something adjacent to direct patient care, trying to improve the organizations and systems that are supposed to be supporting the staff to bring an understanding of care processes.

The third, my employees used to ask me “What do you do all day?! You always ask us questions and work on plans with us, but nothing ever changes.” We would joke about it, but in humor there is truth, and truthfully, they were right. We all knew it, everyone talked about improving, but nothing ever really improved despite constant changes. My fairly standard answer was that I worked really hard at looking busy… They gave me high marks for this. Go with your strengths!

The response to the first is usually, Where do I start? What’s most relevant? What are the challenges you’re facing? I made sure the units were running, from staffing to supplies to systems, designed new things, implemented new things, changed existing things, made lots of suggestions.

The response to the second is, I know. I feel that too. I left my job because I was frustrated as a manager and wanted to work to make things better for clinical staff and patients, I randomly fell into consulting and writing, and I still don’t have a full time job. But maybe that’s why, a sympathetic ear and understanding of the problems they faced can go a long way. We’re all hearing the same message: You have a lot of health care experience, but it’s not important.

So maybe I’m not doing it right and really don’t understand health care!

Couple of things:

1. No, I don’t want to sell medical things… Can I? Very likely, I know how to work the systems and what appeals to clinicians, but it’s not for me.

2. No, I don’t want to do travel nursing. No matter how many times you tempt me with ridiculous paying contracts in Sheboygan.

The message clinicians get from other clinicians in healthcare: You have great experience and you get it, you would be great… Also, hire me when you get a new job you like.

The message clinicians get from companies: Health care experience is nice, but not really necessary. We already have nurses and doctors to take care of patients, we just need someone who can do operations.

To be fair, there are new and existing companies that have clinicians in leadership that provide meaningful guidance and strategy, they are likely growing slower, but they are probably building patient care that just work better.

When I talk to newer companies in health care you tend to find that their clinical operations and care processes are backwards. They are designed from an idealistic outsider perspective of what you think should happen, but that’s not what actually happens. Care processes don’t run from the top down. The reason it’s not what actually happens is because it’s the least efficient use of your highly paid clinicians time. “Our doctors and nurses aren’t working at the top of their license and spend too much time on admin stuff.” Usually the number one complaint. The second complaint, and directly related to this, “we’re having problems with patient engagement.”

That tracks. That’s what is happening in traditional health care organizations as well. They’ve hired legions of advisers and consultants to streamline processes into new ones that don’t work. It’s why everyone is leaving.

People are leaving, it must be the manager.

Managers are important, they set the tone for the unit/area for which they are responsible. More important are the operations, those systems and processes in healthcare that support the people, if those are wrong, then it doesn’t matter how good the manager is, people will be unhappy. The problem now in healthcare is the systems and processes aren’t supporting the people providing care. They are designed by people far removed from care, many who have never treated a patient, creating plans without knowledge of care processes. When these don’t work, they are not re-evaluated or re-imagined, they are layered, one on top of the other, until ultimately compliance becomes impossible. Then we get work arounds, which transfers liability from the organization to the individual.

Many soon to be ex-healthcare heroes have looked at jobs in health care outside of traditional hospitals and care environments, but they’re being told healthcare experience isn’t that valuable beyond the patient, they need people who have designed programs and processes and operations… Which is confusing to us, because we do that… Well, mostly we design processes and operations that work around the ones that don’t work. We do it in sub-optimal conditions, with the tools we have on hand.

There are a lot of people with knowledge of health care, about what isn’t working and what does work that are leaving health care out frustration. Their knowledge is going with them, with all the companies trying to get into health care and all the health systems that can’t find staffing are missing a huge opportunity by passing them over.

Clinical Strategy and Operations.

I’ve seen a lot of comments from nurses and other clinicians about jobs with the titles of “Clinical Innovation,” “Clinical Strategy,” or “Clinical Operations” not actually requiring clinical experience. Usually those comments fall along the lines of:

‘I left a hospital that hired [insert leadership title, clinical transformation consultant] who had no idea what I did all day, no idea what a doctor does all day, never actually worked with patients, and they want to come in and tell me how to do my job, why would I go work for someone else and have the same experience?’

‘It’s clear when leadership has never cared for patients, they don’t get the myriad of problems and challenges we see every day and throw up solutions that don’t work.’

Reddit, Linkedin, Facebook, all have posts from nurses along those lines (maybe others, I only belong to the nurses groups). There are also a lot of nurses that are just fed up and leaving all together.

The message to clinicians is that we are to just work within the system assigned to us, if we don’t like it, then leave. So off we go, and everyone wonders why.

“Gentlemen, we have run out of money. It’s time to start thinking.” - Ernest Rutherford (or Winston Churchill).

Nurses and managers have gotten good at doing more with less, at being creative with what we have to make things work. If you want to know what works, watch the people doing the work, see how it works, ask them how it can be improved.

I’ve sat through countless meetings with consultants, cut support staff here and there, ‘streamline care processes,” give the nurse a phone connected to a call bell. There are thousands of consultants hard at work redesigning processes that cut people out, they often don’t work. There is no meaningful improvement to patient outcomes, no meaningful improvement to patient engagement and satisfaction. And yet, it’s health care, we just throw more money at it, and continue to blame doctors for misaligned incentives.

Can you build a great care program that has great outcomes, engages patients and staff? Sure! Will it make a lot of money? Not huge returns, but you can still make money. You will have happier and healthier patients though… Because that’s the goal…

Clinical teams create the patient experience.

Hospitals focus on creating a spa-like 5 star hotel experience, digital apps have smooth graphics and throw a ton of information online, you can message your doctor at 3am… All these glorious things!

Health care is still a terrible experience, outcomes are not improving and the clinicians are still leaving.

Support clinical teams, give them tools, systems and processes that work to support them in doing their jobs, and they will give you excellent patient engagement and better outcomes. Patients who require more than a transactional healthcare episode will go out of their way to engage with a doctor, nurse, or team they like. Hours out of their way, they will fight their insurance companies, they will bypass other options and go right to the place they like and trust. Patient’s still need a good experience and it should be easy and seamless, there is a lot of improvement to be had. How is the corporate structure and tech stack supporting the people who create the experience?

When a nurse can get a $10k sign on bonus working for a health system in a job we don’t enjoy, what are you offering us that’s different? A nurse or doctor can be disengaged and frustrated in any company, money may not solve every problem, but it sure numbs the pain. There is a shortage of clinical staff, but there are still plenty of clinicians out there not working in healthcare anymore. There is bigger and more severe shortage of companies and organizations that we’re willing to work for.

The question for companies wanting to enter the healthcare space is are you bringing a better care process, or are you just bringing the current mediocrity we already experience into the digital space? For the traditional health care companies, what are you doing that’s different?

So what does a Nurse Manager do?

Short answer: We are the sponges of blame. Staff are leaving, manager’s fault. Dinner trays are late, manager’s fault. Patient fell, manager’s fault. OR wait times are horrendous, Anesthesia and the manager’s fault. Medications are late, well that’s always pharmacy’s fault.

As the managers of clinical areas, we are generally responsible for the care patients receive. Ensuring people practice within their license, regulatory compliance, patient satisfaction, care plans/programs, patient flows, employee satisfaction & performance, process improvements, scaling operations, staffing, resource management, product evaluations, and working with others to come up with improvements to all of the above.

I write this from my experience managing procedural areas in a large hospital, managers for other units will have a slightly different experience, usually more narrow in scope. I’ve worked in several other environments, from physicians offices to clinics and other hospitals. Procedural areas are a combination of ambulatory and in-patient services, nowhere near as large as an OR, more like an ASC. Except we only have control over 35-50% of our patient schedule, we tend to have pretty complicated scheduling, capacity planning, and patient flow issues. In addition, we are typically required to pay more attention to the budgets, inventory, ordering and planning, as supplies and services can vary greatly based on procedure mix (~$1M in a month in some cases), supplies, software, systems and services are unique from in-patient areas. Operations are generally outside of the typical hospital operating environment, and in large hospitals will either fall under peri-operative services, radiology, or a stand alone ambulatory service.

People Things.

I only had 65 direct reports. Only… Many managers have double or triple. With 5 different units spread across a hospital, micromanagement is impossible, thank god, I hate micromanagement. Most of the daily running of the units is done by the charge nurse/tech. They keep the patients moving through the procedural areas and do basic troubleshooting.

Payroll. The single most important thing a manager can do is make sure people are going to get paid. People get very angry if their check doesn’t show up. We got paid bi-weekly, but going through every week is easier. Check the times in/out, who didn’t get lunches and why, who is short hours, do they want to make up the time with vacation, who called out that I forgot to enter in… Call hours, don’t forget to enter call hours, who’s eligible for bonuses? Did people work on other units, get floated or do overtime, make sure to transfer the cost centers. I spent 3 hours every week, and additional 2 hours every other week on payroll Monday. There has to be a better way to do this. Employees have access to their time cards and can put in for PTO if their hours are short, most don’t do it. Why? The screen is incomprehensible, I don’t understand it, the totals don’t make sense, you can’t figure out how many hours short you might be. Creating or finding a better system that works for the employees will improve their satisfaction.

• Better timecard interfaces for the staff.

• Better scheduling options that can be done online.

Daily Huddles. When everything is going right and I haven’t had a disaster overnight, it’s how the day starts. Every unit charge person on the phone going over how we think the day will go, any potential issues, any unknown issues (rumors), how many outpatients, how many will be admitted, how many will go home, how many transfers, how many known inpatients. Any staffing issues, do lunch reliefs look OK? Lunch is the most important meal of the day, make sure people get a break.

The Daily Walk. Twice a day to each of the units, most days, some days I couldn’t, every day at work I walked at least 5 miles. Just checking in and seeing how everything is going, stop by the other cardiac units to check in. Sometimes you cover the charge person while they go relieve people for a break. Sometimes you relieve them because there’s a code going on in one of the rooms. Sometimes you go into a case and actually be a nurse… Keep up the annual competencies. Covering for staff is eye opening, it didn’t happen often, but when it did it really highlights the workarounds and impacts of all the little changes to systems that happen outside the procedural areas. Take lots of notes and ask about them, there has to be a better way. Take a patient back to the recovery area or back to their unit on my way back, ask about their experience, they usually sang the praises of the staff and doctors, write that down remember to tell the staff. Talking with the physicians, asking how things were going, what did they need, ask them to stop trying to break the system, I know it’s not working well but it’s not good for the staff. The problem with breaking a system is that you break the people before the system breaks.

Personnel Issues. 65 Direct reports. 5 different charge people on a daily rotation. There was an issue every day. Usually it was because of patient flow issues, frustrations with systems, people were annoyed and snappy, and someone gets offended. Everything is forgotten an hour later, nobody is really mad at each other, they all know it, but tensions can mount when nothing is going to plan, sometimes they snap at me, sometimes they snap at each other. I’d prefer they snap at me rather than each other though. The systems and processes don’t work and people are getting frustrated.

Just culture, who’s ultimately at fault? There has been a fair amount of press about nurses being charged with crimes. RaDonda Vaught is a name every nurse knows. Everyone in health care is acutely aware of liability, we don’t want to harm our patients, we want to help, but we don’t really believe that the system will stand behind us. Systems protect themselves, not individuals. The systems and processes and checklists make it increasingly difficult to this. We cannot blame an individual for a system issue, but, are we actually changing the system to solve the problem? Or, do we add another system and process on top to try and cover up that hole in the swiss cheese rather creating cheese with fewer holes? We create so many opportunities for work- around by adding more processes to broken systems, and we continue to ask fewer people to do more of the work.

Career Development. With 65 direct reports it’s hard to keep track of everyone. We have systems in place to track licensing and certification, but they are often cumbersome and weirdly configured. I just created an excel spreadsheet to track everyone’s licensing and certification in one spot, much easier.

• Customizable screens and reports would definitely help here. The information is in the system, it just needs to be presented better.

Professional advancement is usually the answer we get to creating more engagement. Except there are two problems with this, 1) not everyone wants to advance, some people just want to be really good nurses, and 2) as you move up the advancement ladder, you are supposed to get more “office time” to do all the things, except you can’t. We don’t get another staff member to make up for this, and if staffing is already tight, then forget it.

I’ve been through this during staffing and budgeting meetings. “Non-Productive Time” is usually accounted for in figuring out staffing. Except, the longer a nurse has been with the organization the more vacation time they get, the higher up the clinical ladder they go, the more office time they should be getting. Procedural managers are probably acutely aware of this, we hire experienced nurses, more tenure, more vacation time. To begin with staffing calculations don’t actually allow for covering every shift, there is usually a 10-20% difference that is made up for with overtime. The problem compounds the more seniority have, you can prove it, but you’re told that you can’t increase the budget.

• Realistic staffing levels. Constant under-staffing is a drain on moral.

Staffing Reviews. Monthly review staffing with the staffing coordinator. What’s current staffing look like, what does future staffing look like (pregnancies, extended leaves), any needs, shortages, travel/agency requirements. Many hospitals have certain criteria for vacancy before you can bring in a contract person, 15%-20%-25%, it can vary. Review our budgeted FTEs and actual FTEs. Discuss staffing challenges, can we use internal float pool? Usually we can’t because of the experience and skills required, they are fairly unique, there is some opportunity to cross train, but the others areas have worse staffing than I do so they would get dibs on the people with the experience needed.

Why would I turn down 2 travelers that the agency sent over? They used to work for me, I’m not putting them back on the unit with their former co-workers when they are making $8k - $10k PER WEEK, that’s completely demoralizing, there are other travelers out there to help. Staffing was good until agency rates went through the roof. You can’t compete with that. Nurse that’s planning a wedding, go take two three month contracts and pay for the wedding, pay for a house, pay for a car… The staff took advantage of it, and I don’t blame them. I would bring them back full time, but not as a contract employee. They knew this, I was clear about it.

When procedural units have to operate 24/7 but are only fully staffed during the day, staff are assigned call shifts for emergencies. Emergency caths after normal operating hours require a certain number of staff to come in, usually within 30 minutes of the notification. This creates scheduling challenges, needs to be balanced, if there’s a call early in the morning, maybe they won’t be able to work the whole next day. The staff want to look at different staffing models, I discussed it with them and came up with two different ones that I’d like to present. One will require a new FTE, the other one will save money on overtime but not require additional staff. The one requiring an additional FTE is a no go. I knew that. Go through the first one… Can’t be done, it’s too hard to figure out how to pay them and it wouldn’t be fair to other units to have such a different staffing model. So, we’re stuck with the same model and exhausted staff. There’s no flexibility in the system to allow for novel approaches to retain staff, improve satisfaction, and likely improve patient outcomes.

• Flexible staffing models would allow managers to create ones that work for their unit.

Staff Meetings. 6:30, 7am… Or whatever worked, sometimes they were impromptu if it turned out it was a slow day. Nobody retains anything from the staff meeting. Email the notes from the staff meeting, post them in the break room… Whatever, nobody remembers, until you have to give bad news. Everyone remembers the bad news! Joint Commission reminders (make sure the drinks are covered and only in the designated areas), practice reminders, review chart audit results, review operational metrics (questions or thoughts on the results, ways to improve), training/education that needs to be done, hospital initiatives, <<insert profession>> appreciation week and empty platitudes… All the problems mentioned above (and further down) have a direct impact on staff and their ability to take care of patients, and yet they seemingly never get solved. We just create more things for them to do to cover the up the holes. It’s difficult to stand in front of staff week after week, month after month, going over the same problems and telling them “I’m trying.” Yet nothing ever changes, I totally get why they’re frustrated.

Performance Reviews. Generally the senior staff compiled feedback for annual reviews, I would review them, make changes, assign ratings, and review with the employee. I did these once a month for the employees due for annual reviews that month. No, they weren’t all done at the same time. Why? It’s based on the date of hire or promotion, and that’s the way we’ve always done it. Can we change to a set annual review date for all staff so it’s easier for people to see impact to unit goals and metrics by having them all done at the same time? No, see the previous sentence. It is actually difficult to measure the individual’s contribution to a unit goal, when they may only be a month out of setting that annual goal for the unit. It’s goofy. It requires a lot of individual tracking of projects and results. There’s a spreadsheet for that though.

Another conundrum with performance reviews… The difference between meeting and exceeding expectations is 0.25 – 0.5% in an annual raise. Is it worth it to bust your ass for 0.25-0.5%? No. If a nurse is exceeding expectations we tell them to climb the clinical advancement ladder! More work, you get a meaningful raise, but you have higher expectations… But staffing is short, so you won’t have time to meet the higher expectations. Nobody really wants to look at compensation structure beyond how we compare to other “similar” institutions. We want to be middle of the road for pay, but expect above average work from staff. Nobody sees the irony in that one, except the staff.

• Better tools to help employees manage their own careers would be great. What areas do they want to focus on? What training classes are available? These things are out there, but the information is scattered.

• Compensation structures that reward performance, maybe a bonus.

Employee Satisfaction Surveys. There’s nothing more satisfying than taking the employee satisfaction survey, you get to express your opinions enlighten management about where the problems are, let them know how things could be better, all things that will improve your working experience! HA!

I would spend hours talking about the survey with staff, the complaints were always the same, they ask us questions but don’t allow us to add details.

We would review the surveys and work with staff to come up with ‘action plans’ to improve morale and engagement. Except, the issues are systemic, not individual, can we change the system to something that is responsive to the employees? No, the system is not to blame, the manager must be doing something wrong.

Annual Training. Online hospital wide annual training. I’m sure every organization has something like this. In addition to the hospital-wide training, there are unit competencies every year that we must to demonstrate competence with in the given field. This involves training and education on equipment, safety issues, common conditions, emergency response, radiation safety. These were typically done in “marathon” sessions once a year, which never made sense to me, why pack it all in one or two days? Worked with an educator to split them up into monthly activities, different topic each month.

I kept up with the competencies for the staff, mostly, I tried to attend each one but sometimes couldn’t. In addition to all the competencies that staff have to do, managers do more. Having authority to commit funds, hire and fire means we have more online training modules. EMTALA, AKBS, Stark Laws, PQSIA, Billing Laws, EEO, and many many more.

My Annual Review. I actually got pretty highly rated, not sure why, I felt like I wasn’t making a difference most of the time, but the staff seemed to like me. My bosses were great, annual reviews were kind of cut and dry, just that, a review. They gave me constant feedback throughout the year, and I did my best to respond and adjust. But it also comes back to that conundrum, do I continue to bust my ass for an extra 0.5% raise? The answer is no, I bust my ass because I still have 65 nurses and techs busting their ass to care for patients.

The Boss. Correction… Bosses – Point of clarification before you read, I liked all my bosses, they were great, but there was a lot going on. As a nurse manager I had a Director of Nursing, I also had a Cardiology Director, who’s not a nurse, he was a Radiology Tech by training. What about the doctors? They don’t work for the hospital, we work collaboratively, except when we don’t, they want to do more, the hospital wants to do just enough… Constant tension.

When I first took over as manager, I reported to an SVP of Nursing. Who had no time for me, not her fault, she would make time when I asked and always answered my questions, but she oversaw all the inpatient areas… As a new manager, there was a lot I didn’t know, there was a lot I didn’t know I didn’t know. Six months later we got a Cardiology Director. Weekly meetings with the Cardiology Director. 3 years later our leadership structure changes so we report to Peri-Operative Services. Instead of being lost in the in-patient world, we’re lost in the Operating Room world. Weekly meeting with the Interim Director of Nursing.

• There are better structures that can help better manage areas, more on that below. Often the focus is on adding more layers, rather than broadening and flattening the structure.

What’s going right, what’s going wrong, what do we need to be doing better, are there areas we can focus on… What did we talk about last week? I felt good when I was told that my areas are doing great, but I know we could be doing better if we could get these things addressed, here are some ideas… We’re not the priority, there are other areas with more pressing issues.

Patient Things.

Patient Satisfaction Surveys, aka: HCAHPS. Staff always got high marks. I’m not saying they were perfect, but they were really good. The problems? Scheduling, coordination, post discharge appointments, discharge instructions, all those systems issues. It is incumbent on the manager to fix those things. Back to using my dashing good looks and razor sharp wit to get what’s needed. Almost every day I had a patient complaining about insurance, us not having records we should have, waiting for a bed, their procedure being delayed. There’s only so many times you can stand there and say “I know, I apologize, we’re doing our best to...” I can offer a coupon for $5 to spend on food in the hospital, in a cruel twist of fate they can’t use it because they’re waiting for a procedure. I can offer to pay for their parking

Patient’s become disengaged, act out, become “non-compliant,” and lost to follow-up most often because of the barriers we put up. Especially patients without the means to afford high quality insurance, primary care, support or navigation. Health care workers are the ones talking to patients and trying to smooth things over, but they are also representation of a health system that is failing the patient. All these challenges facing health care workers are even more frustrating for patients on the receiving end of this care. For patients that are being neglected by the system, acting out often gets attention. The experience won’t improve until we improve the system.

Here’s an interesting podcast about the Patient Experience.

Patient flow. Constant problem and by far the single biggest time suck, for everyone. There were never enough beds in the hospital. Prep & Recovery nurse calls, one of our physicians just accepted a transfer and they’re on the way. Heart Center nurse calls, insurance won’t cover the patient’s procedure here. What does that even mean? The patient will get a bill for the full amount of the procedure. <<sigh>> What’s the right thing to do? Stop the transfer? Maybe, how urgent is it? Can we find another hospital to accept and divert the ambulance? Do we turn them around? Should any of this even be a question? NO. It’s not fair to the patient, but is it fair for the patient to receive a bill for tens of thousands of dollars? NO, nothing about it is fair, nothing about it is right. The sending hospital never called report and the charge nurse for the prep & recovery unit can’t get them on the phone, and there’s a stack of papers that’s a print out from their EHR. Buried in there is an H&P. There’s still no beds… What’s likely to become available later? What’s the backlog look like? The patient in the ER will have to wait a little longer for a bed.

• So many opportunities to improve this process. But it involves changing how patients are brought in, how transfers are accepted, and nobody wants to tackle that or enforce processes that are already in place. The manager ends up being the bad guy. The patient “had to” come here “now”. When everything is an emergency, nothing is, when everything is an exception, there is no process. We end up with grid lock.

Patient Scheduling. Reviewing the upcoming outpatient schedule, look for red flags, chat with our scheduling nurses, address any potential issues. We need more anesthesia time, chat with the Anesthesia director, no more availability. Ask the nurse to take a deeper dive into the patients that might be marginal for anesthesia, check the unit schedule to see who’s working, chat with them about comfort giving sedation given the patient’s history. The two most frequent problems with scheduling patients was around insurance approval and lab results.

20% of lab work had an issue, it was drawn wrong, tests weren’t run, results weren’t uploaded. It’s a constant source of frustration. The scheduling nurse knew which labs the most reliable and tried to steer patients to them, but sometimes it couldn’t be done. Drawing labs the morning of the procedure risks a cancellation or delay if there is something off.

Getting all the information from the referring physician was another challenge. Fax machine to the rescue! Despite everyone having EHRs, it was still easier to fax an H&P. Crazy right?

• Better interoperability. For whatever reason, we still can’t seem to handle transmitting basic information back and forth.

Creating protocols so Nurses handle the most common issues with pre-op instructions that require a physician order, things like changing medications. Why? 80% of the changes to medications can be done because they fall inside the norm and don’t really need the doctor’s time, the other 20% require more rigor.

Pre- and Post patient instruction offers another area for improvement. There is a lot of time spent on the phone with patients, and people often forget what you tell them after they hang up or leave the facility.

• Better messaging options. Patient’s don’t log into their portal because it’s cumbersome and confusing, so they often don’t check messages on there. Why not allow patients to forward their messages to their email? Pre and post-op instructions can be sent there.

• Better messaging. LLMs probably offer a lot of hope here, being able to summarize information and present it in an understandable format for the patient.

• Videos for pre and post operative information, maybe a QR code on discharge instructions that links to them.

Systems/IT things.

Not every day, but almost every day. 5 fluoroscopy systems, 2 different manufacturers, 25 different interconnected systems and equipment for various procedures, 2 different monitoring and documentation platforms (separate from the EHR), PACS/VNA systems. Something always breaks, if it’s less than twice a week, it was a good week. Text message from staff telling me a room or piece of equipment is down. They already called IT and BioMed and Radiology IT, and they did the localized trouble shooting (checking connections, making sure a cable wasn’t run over with the Echo Machine), they followed the process… They’re working on it. Ask how it impacts flow, “we’re OK right now.” Let me know if you need me to call anyone or do anything else.

• Several opportunities here for improving operations and staff satisfaction. Talked a little bit about this with Vik Patel over at Tido Inc., check out the podcast here. How are problems detected? Usually by staff, who then have to troubleshoot, then call IT. But there is more than one IT department, or maybe it’s Biomed. We develop a workflow for that through trial and error. There’s pages in a binder with different workflows for different problems.

Systems upgrades. I’m not too sure there is much to be done here, it’s just a lot of coordination and making sure it doesn’t impact patient flow since we can’t just shut down operations for a whole day. Depending on the how extensive the change is to user interface, there can be a variety of training challenges, getting super users and running through the whole thing with them, making sure everyone is set to go for it and on the same page. Having good relationships with the vendors and IT teams is important, their support is key, especially right after the implementation. There was one complete upgrade (hardware + software) that went through with no problems, otherwise, there is always a problem. With so many interconnected systems, there’s one thing we missed. Every staff member knows this, and if the computers don’t blow up when we turn them on, we consider it a win.

Hospital systems.

New upgrades to things, new software for things, new things. Prepare staff for deployment, make sure they do any required training and they know when to expect it. Nobody has any expectations that new systems will work as we’re told they will, because that has not been the experience. Every new system has put more work on the clinical staff.

EHRs. I’ve covered this in other writings, so I’ll just leave it that EHR roll-outs are always a complete disaster. I’ve worked at a few hospitals when this was being done. It’s a nightmare, before, during, and after roll out.

The User Design Committee. This group worked on updates to the EHR interfaces, processes and workflows. I was the representative for the procedural areas on this one. Everyone wants a better process, a better workflow, a better interface. We are frequently disappointed. We take feedback from the staff and physicians about what they find frustrating, work on a solution, and present it to the committee. By the time the proposal gets back around to us it looks nothing like what we requested and won’t actually help with what we were trying to accomplish.

• Move back to focusing on the clinicians, they are the highest paid staff in the hospital, optimizing their time saves money and improves morale.

Operations

Every day there are operational challenges. Much of the operational issues are covered in other areas, but there were a lot of meetings on how to improve things. One thing to always be mindful of is how a change in one thing impacts other things. What gets measured gets managed. Common line, and true. But what are the impacts of measuring something? If we measure prep time in the prep area, do we have more problems down stream with patients not being adequately prepped?

Delays, down-time, overtime, call time, all the issues. Any new trends, new issues, ongoing issues. Follow-up with the previous week’s issues. Make notes for the monthly meetings. Are we measuring the right things?

Quality Metrics. Patient outcomes, adverse events, re-admissions. Checking out these metrics and looking for trends, possible causes. Conducting investigations into what happened and preparing reports. Making notes for the monthly meeting. Work with the staff to track complications and issues. We set up monthly inter-disciplinary to review any safety issues, adverse outcomes, events. These involved our medical directors, risk management, and any other staff that may have been involved in the issue we were looking at. Take a dive into the problem, or almost problem, did we do something that almost harmed a patient, how can we avoid these in the future.

• There are so many opportunities to improve capturing patient information and outcomes. Hopefully this is where AI/LLMs will have a big impact in the hospital environment. Getting all those details captured in notes and different areas of the chart to actually provide insight. The staff knows what works and what doesn’t, it’s in there, it’s just buried under everything.

Investigations. These are fun, I get to play Sherlock Holmes and snoop around, get all up in people’s business. Not really, but I can pretend.

Drug diversions. Managers get an alert based on algorithms about narcotics being pulled, if a nurse pulls too many, an alert pops up. Investigate it, think to yourself ‘I always knew Nurse Sally was a little too happy in the morning.’ This usually involves going through the charts of all the patients the nurse took care of and checking documentation, administration, and waste. I’ve never had a nurse diverting drugs, thankfully, but the alerts will typically pop up when a nurse is on orientation, because they are administering more drugs.

Billing and documentation investigations were always tedious and time consuming. Investigate documentation and claims, make sure we were billing for the right things. If there were constant problems with a certain code, how do we fix that? The answer is always to add a new dot phrase, documentation training resembles morse code more than it does patient care.

Regulatory Compliance. The amount of regulatory compliance and documentation is crazy. A lot of it is redundant, sometimes we don’t need another policy, we just have to be able to speak to how the policy fits a particular regulation.

JCAHO is probably the most well known accrediting body, and is constantly on the mind of everyone. Every employee in a hospital knows about the JCAHO shuffle. It’s the weeks before a visit where everyone is hyper focused on making sure everything looks pretty and everybody knows what to do and what to say. If you have any maintenance issues that need to get addressed, this is the time to do it, because it will usually get fixed the next day. Otherwise, it can take weeks to get things fixed. Why? I actually have no idea, there are more people fixing things during these weeks, do they bring in extra maintenance people? Maybe. I’ve never asked, I probably should’ve. The staff are usually well prepared for this, they know their jobs, they know the policies, the biggest thing is to remind them not be nervous.

What does JCAHO look at? EVERYTHING. It’s like colonoscopy, only more invasive. General facility conditions, environment safety and safeguards, employee knowledge of processes and procedures, employee licensing and ongoing training, policies and procedures, and so much more. The auditors will randomly pull employee files and sit with the manager to go through them to evaluate documentation of education, training, and competencies. They will pull policies and procedures and ask staff about them. They will ask staff to find information in charts, which has always been noted as a prevalent problem throughout every facility (thank you EHRs).

The auditors tend to be nice, if you’re nice to them they will work through nerves and walk you through things. It tends to be the administration that causes more nervousness among staff than the actual auditors.

There are other regulatory agencies that we have to comply with beyond CMS. State regulations, departments of health, radiation safety regulations, building codes.

There are also independent accrediting bodies. Magnet, Leap Frog, SCAI, the list is ever growing. Are they worth it? With every facility facing the same issues, are they truly making a difference, or does it just mean we get more flair for our lanyards? I think the intent is great, but the jury is still out. Most employees aren’t convinced they make a difference.

Operational Meetings. Several larger meetings with the health system, practices, physicians, administrators, and a few other characters. What are the operational issues, what problems are we having with referrals, who’s referring, scheduling issues, pre-op issues, post-op issues… The whole gamut of operations, from the first fax to the last one. Brainstorm ideas to improve processes, streamline operations, reduce backlogs.

Check the metrics for the month, spent a lot of time with our data analysts to get the dashboard right, and get the right data. This is both interesting and frustrating. Nobody wants to change what they do, everyone wants to change what everyone else does, navigating that is challenging, keeping the focus on the big picture and the patient’s experience can be difficult when getting into the weeds on these discussions. There’s a lot of discussion of different processes and procedures that are taken by others, how and where each interact, and how we can improve the exchange of information and coordination. Questions surrounding capacity and volumes, if we increase referrals, do we actually have the capacity to handle the patients?

Is it better to do 1 case per day at 100% utilization, or 5 cases per day at 85% utilization? That depends… Do the 5 cases use or need the mix of different and very expensive equipment and staff we have? Meaning, if we’re not utilizing the full capabilities, then maybe the patients can be served just as well somewhere else. Administrators will give you funny looks if you recommend sending patients to another lower-cost location. It can be more cost effective to treat fewer patients at higher utilization, with less demand on inpatient beds. It can also be more worthwhile to treat higher volumes of patients with fewer needs, it all depends. Play a numbers game. Is that better for patients? Well… That depends...

If you want to roll out that dashboard we created to every other facility, then you have to make sure you’re all documenting the times in the same place in the EHR… There are a few different places to document this, who knew?! Different facilities document in different places in the same EHR and call the times slightly different things. There are two times that are all documented in the same place because they are used for billing, those times defined by insurance reimbursement. Why are the other times labeled different? When the EHR was implemented they just asked each location where they wanted to document and what they called a certain time, and that’s how it was labeled. As the locations increased, so did the number of different time definitions.

Introducing new procedures or programs. How will this work, what do we need, what do the referrals looks like, what does the patient flow look like, is there a need for hospitalization, is there a need for anesthesia, who does post discharge follow-up? So many more questions along these lines.

I worked on a couple of different projects, and this is where I wanted to focus, its what I found most interesting. How do the processes, systems, workflows, and other support mechanisms impact the people giving the care, what can we do better? Can it be cost effective when step back and look at the bigger picture. When I was made interim manager of the cath lab we ran through an exercise of what a better organizational structure looked like. Did it make sense to have a manager for each of my areas, or have a different structure? I proposed one, splitting the structure into a nurse manager, operational manager, and admin manager. Net effect is no change in the number of managers, just the area of responsibility, rather than individual units, there is responsibility for different processes. They would need to work together collaboratively. In the procedural world there is a lot of overlap, and this way the you could scale to different areas without necessarily adding undue burden or additional administration.

• Nurse Manager – Responsible for patient care and employee performance. Would be an RN due to practice oversight.

• Operations Manager – Responsible for all the financial things, operational reporting, projects, patient movement, capital purchasing/planning. This would be an RN or Rad Tech. This also offers technologists an opportunity to advance into leadership, something that often doesn’t have a clear pathway in the hospitals which are focused on nurses.

• Admin Manager – Responsible for admin performance, billing, scheduling, supplies, coordination with physicians. We had one, and this is what he did. It worked well, I didn’t necessarily have to worry about most of it, only when my knowledge of cardiology was required.

The advantage of this structure, in my mind at least, is that you can add any other ambulatory nurse/technologist manager who can oversee practice and have them focus on the practice of that skill. The other stuff is taken care of by others who have a clear clinical background and understanding. For instance, my interest is how operations and workflows can help nurses provide better care and enable practice, it is not in the practice of nursing itself, that leads towards an operational role, not a practice role. There are many others with similarly diverging interests, using their patient care background to inform on how different processes and actions can support the patient care teams. I got shot down, but I tried… I did find out a few weeks ago, this is a structure they changed to, except they are now reporting to a Director of Nursing, not a Director (subtle difference, but it can be meaningful).

Emergencies. Generally few and far between. Every once in a while they happen, and you have to adjust. Patient emergencies staff are well equipped to deal with. A flaming trash rolling through your cath lab? Not as much. Thankfully there were no patients in the lab at the time, but it can happen.

Covid. The elephant in the room. Massive upheaval to operations. I’ll start by saying it is much easier to turn everything off than it is to start everything back up. When ambulatory procedures were suspended it doesn’t take a rocket scientist to figure out that someone upstairs is going to want your staff. You have highly trained staff sitting around doing not a whole lot. Once shut down was lasting more than a couple of weeks, I started working with other managers to float staff to help them. Nobody really liked this, but I did talk it over with them, and they would rather go to the same place where they could be helpful, rather than being randomly assigned each day. This worked well, for a while… It eventually morphed into a thing, create a spreadsheet for all of peri-op to manage excess staff and assignments, we all worked to try and get people to consistent places so there was familiarity.

The hospital I worked for did not lay off any staff for reduced operations. Staff were re- assigned, as I mentioned above, and there were opportunities for overtime to help with new processes and procedures. It actually worked fairly well. Perfect? No, but better than most things. The managers were involved in these processes, and matching staff with skill set and locations was done as much as possible.

Moving a prep and recovery unit requires a lot of coordination with every part of the organization. Moving an active unit in a few hours while patients are in procedures is even crazier. It was a massive effort on the part of staff and the tech teams. We were all rolling equipment through the hospital, on carts, chairs, whatever. Supplies took a while to get sorted out, and there were things I could’ve been more on top of, but it worked OK.

Covid testing pre-op. Lots of challenges with this one. Initially a lack of test availability was the problem. The logistics of getting patient’s test within a day or two of their procedure and getting the results, is harder than you would think (lost tests are surprisingly common). Sometimes labs wouldn’t get the results back in time, so you have to set up a procedure for testing patients the morning of. It added a wrinkle to the flow, re-arranging schedules at the last minute, hours of frustration for the scheduling nurses.

Where do COVID+ patients go that need a procedure? What about emergency cardiac patients who’s symptoms mirror Covid? We have immunocompromised patients frequently, how do you set up that workflow, making sure they’re not in the area at the same time? Facilities was pretty cool in building a negative pressure antechamber and I worked with the staff to get a procedure that worked.

Starting procedures back up you have to start pulling staff back, figuring out how to make sure patients can get done, safely. It was a challenge, but it was interesting. The best part, since nobody was really sure of anything, clinical staff were heavily involved in planning and designing these workflows. They didn’t always work perfectly, it may never with so many moving parts that keep changing, but they did a great job making things work.

Inventory and Supply.

Ordering Supplies. Don’t forget to approve the supply orders and purchase tickets before 1pm, otherwise the items we need for tomorrow won’t get delivered on time. 15 primary suppliers for different procedures and products separate from normal hospital contracting, and average of $150K in daily purchases.

Why do I have a breast implant on my desk? The thing about the ordering system, there are no pictures, and the descriptions can leave a lot to be desired, you get some strange things if you transpose one number. How much is spent on the wrong products? Did the products get returned? There’s a huge amount of labor spent tracking a return and making sure credit was received. For smaller items we would try and swap supplies with other departments, IR, the ORs, it was just easier. Sometimes you go outside the normal purchasing flow, EKG cables are on back order, and we can’t get another supplier. What do we do now? Amazon! I purchase them on my account and submit for reimbursement.

• Internal systems leave a lot to be desired. They are not the user friendly experience we find out in the world at large. They are designed to please the back-office operations, not the people using them for front office operations. It’s important to track which boob ordered the boob.

The daily orders were done by a staff member, who would go through the shelves, write down what’s needed, the unit admin would enter the order, and I would approve. This maddeningly manual process can definitely be improved, and there are systems to improve it. How much time would it save the staff? About an hour every day. ROI on an investment like that? 20%, plus there’s likely an additional $200K in freed up capital from inventory reductions. The catch? The savings comes from increased efficiency, there is no line item to point to cost savings, only the expense. The benefit comes from freeing up staff to do more meaningful things.

Getting supplies to the unit… Sounds pretty simple right? I mean, we can get the world delivered to our front door, why can’t we get supplies delivered to the unit. This is a challenge that is pervasive in hospitals. In the effort to cut costs these tasks get pushed up to the nurses and techs. Even a few minutes multiplied across units adds up to hours. Linen, food trays, medications, supplies, all of these items that individually may not sound like much, all add up. But again, different cost centers bear the burden of this, it’s easy to eliminate a position when the decreased efficiency is buried somewhere else.

The health care supply chain is complex. Hospitals will contract out inventory and supply controls to a third party purchasing and aggregating company. They can save money, but when internal inventory control is contracted out, it can become… problematic. There needs to be strong oversight, but there seldom is because we cut the entire leadership structure, they all now work for the contractor and not the hospital. If people aren’t happy with the contractor it can go out to bid again, but changing suppliers like that brings about massive upheaval, so nobody wants to do it unless there are massive problems, little problems persist.

Vendors/Sales People. I liked my reps, they were all good. They were always around because they had specialized training on the equipment that we used and were needed to safely operate equipment like 3D mapping systems, vascular imaging systems, some pacing systems, ICD and Pacemaker implants, and other things that we didn’t use that often. Always at least one rep in the labs every day. They always wanted to chat with me about the new product coming out, the service agreement that expired last month, new products and services.

For any sales people new or old who may not know… If the physician sends you directly to the manager (me) to talk about a product, they probably aren’t interested. If they listen to you, then bring you to me or email me about you and say to call them back in a week, then they’re interested. It’s how I knew whether or not to spend time on engaging the rep and getting a product through the contracting and purchasing process (more on that later).

One thing that seems to confuse new companies selling into healthcare organizations… Know the organization and who you are talking to. Are you selling to the hospital? The physician practice? The outpatient clinic? The ASC? They are all different corporations.

How many different corporations do you have to sell to? Does the system have integrated purchasing, or do you have to go through each hospital and practice. How aligned are IT systems if the service requires IT integration? Different IT teams at different locations? How many IT teams are there, Radiology, Cardiology, Peri-Op, In-patient? Separate BAAs, or a single one? Separate VRA’s, or a single one? Lots of questions and details to make the process smoother. If the manager is engaged and wants the product or service, they will walk you through this process.

Food/Meals/Education. Vendors like to bring food, lunch or breakfast. We like vendors for that. Vendors like to sell things and increase utilization of their products. We don’t like vendors for that. Food gets people’s attention, or at least gets them in one place for a little while, so that’s why vendors bring food. I said we had good vendors, we really did. Ever dissected a heart at work? One of our vendors made it happen for the nurses to teach physiology and conduction (it was a lamb’s heart). Need education about the basics of rhythm control and pacing? Our vendors do that. There is a lot of value added beyond just the product. Does it work to increase sales? Sometimes… Just being front of mind will increase utilization. Does it mean we use a more expensive product? No. They’re all generally priced about the same, they do their market research, they all know each others prices.

A question I’ve seen a lot from new companies… Yes, you will be asked to bring in food for more than just the physicians. You will be asked to bring in food for everyone... EVERYONE. From housekeeping to the Medical Director, be prepared to feed us and teach us, yes teaching needs to be part of the equation. Also, make sure you get a list of who was there for the federal reporting requirements.

Clinical Quality Value Analysis Committee – Cardiology. Looking at the products and services that we contract with and how we bring new products and services into the medical system. Get results ready from products we’re trialing, set up new evaluations for products we’re proposing, run the final numbers on products we’ve finished evaluating. This committee works to rationalize and normalize all the different products and services throughout the whole medical system. This was interesting, I worked with the coordinator from the system to help get this up and running. Physician wants to get a new product or service. Get the details, does it replace an existing one? Does it improve outcomes? Does it save time? Does it improve re-admission rates? Does it reduce complications? Does it increase direct costs but reduce overall costs of care? How much does it cost? Is it just a product that is preferred over an existing product, if so why and what’s the cost difference? Lots of questions, design evaluations to answer the relevant ones.

Anyone who has tried to sell to a health system knows about these committees. We’re really not that bad. The hard part is getting doctors to agree… They’re all deferential to each and nobody wants to tell the other what to do or how to do it. There are ways around this, mainly through aggregating purchasing contracts, so that the physicians still get their preference, but the hospital saves money.

Another consideration with any change or addition is how it will impact everything else. What other areas, systems and processes are involved and need to be considered as part of this decision process.

The most painful part of any contracting process? The attorney’s red-lines. Months of back and forth. If it’s a new vendor, the BAA and VRA. Another headache. I’ve walked so many vendors through this process, and it’s so frustrating…

Financial Things.

The most important is, of course, the last…

The general feeling I got in regards to investments in many of the areas I mentioned above, was that my units were running fine, you don’t need any attention or additional resources, just keeping printing money with procedures. Things work fine, until all that deferred maintenance catches up. It eventually does.

Budget meetings. These were fun. Not really, but I understood the budgets and knew my numbers so they were relatively easy, after the first year I figured out how to get some new things. Nurse educator position, check, new PCT position, check. The problem, anything that is an impact beyond your cost centers doesn’t matter. If I could show “synergies” beyond a single cost center of mine, then I had a better chance of getting things approved.

There were monthly meetings where we reviewed variances, staffing expense, supply expense, every other expense. I had a great analyst, he came down and toured the units so he had a better understanding of what we did.

Annual budget meetings were more focused on the future. Systems needs, potential upgrades, new procedures coming.

Long term capital expenditures, who follows this? It’s a good question to ask, it’s probably not who you think it is, if anyone at all. BioMed? IT? The unit manager? This was an ad hoc project by the director and myself to put together a complete asset list and end of life analysis… This is kind of important, but for some reason all to often replacement schedules are ignored until it comes up as a “we have to do this now!”

Anticipated service contract changes, pricing increases, or decreases. Having a good relationship with vendors can help with this. They may not be able to give you exact guidance, but will help understand the direction of pricing, changes to service programs coming up, and new systems or offerings that we may want.

Always chat with the physicians, nurses, techs and pay attention to industry trends. What can we expect in the way of new procedures, products or services from outside our current vendors.

New Labs. This doesn’t happen often, but I’ve been around for 2 EP Lab replacements and 1 Cath Lab replacement. The clinical teams weren’t brought in until after the plans had been drawn and sent out to bid. The reason? They did the plans based on the current space set up and according to code. Code is the minimum. The minimum may be OK for a lab that doesn’t do complex procedures and interventions, but for a teaching and research facility that utilizes a lot of specialized equipment, the minimum will never be OK. To accommodate all the equipment the plans had to be changed, so of course I was the problem child and caused cost overruns. Oh well. Maybe I shouldn’t have asked for open concept and a ship lap feature wall. If you’re going to design a procedure room it’s probably best to have the people who do the procedures in the process early on. This will give you more realistic requirements to budget and work with. The same is true in many other areas of health care.

Other Things.

There were many other things I did as a manager too. Rolling out services to other areas and hospitals, advising on lab space construction for a new hospital, working with other managers on patient flow, different initiatives and executive meetings, all sorts of other ad hoc commitments where subject matter expertise is required.

You made it to the end!

So that’s what a manager does all day! LOL I’m sure there are things I missed. Many of these tasks were taken from an “instruction” book I left for my replacement.

It was an interesting job, but ultimately frustrating. You can see why things aren’t working, you understand ways they can work better, but you’re also getting lost in the noise. Speak too loudly and you’re a troublemaker, speak too softly and you never get heard. There are plans and systems implemented every day without clinician input that only lead to more headaches and more burnout.

I don’t think clinicians need to be the top dog, but they definitely need a strong voice at the table when it comes to patient’s care and treatments and the processes that go into making those happen. There is room for us to learn from others too and apply that knowledge to patient care processes. We’re incredibly adaptable, we can see lots of uses for things, and many ways to make things better.

What are areas others have been frustrated with? Where can the smaller and larger systems be improved to help clinical teams?

Thanks for reading! Always feel free to reach out to me on LinkedIn.