Lorna Rothery spoke to Pedro Delgado, Vice President of the Institute for Healthcare Improvement about how solutions to the healthcare workforce crisis can be implemented positively and holistically.
How can we support organisations to prioritise the health, wellbeing and careers of staff? This question forms the basis of our conversation with Vice President of the Institute for Healthcare Improvement (IHI), Pedro Delgado. Healthcare workforce challenges are present across the sector, though exacerbated by the COVID-19 pandemic, are not anything new. But as health systems are increasingly buckling under mounting pressures, leaders must look to sustainable solutions that ensure staff are supported holistically across their careers, and positive measures are introduced at both local and national levels, in healthcare and beyond, that can benefit and nurture all interested in the medical profession. The IHI’s mission is simple: improve health and healthcare worldwide. The independent not-for-profit organisation endeavours to effect positive change by partnering with visionaries, leaders, and point-of-care practitioners around the globe. Lorna Rothery spoke to Pedro Delgado about the key drivers behind the current healthcare workforce crisis, and how these can be addressed.
What is the role of IHI within the wider healthcare landscape and what have been some of your key focus areas over the past year?
IHI has an aspirational mission: to improve health and healthcare worldwide. In other words, to achieve better health, better care, at sustainable costs, delivered by healthy staff, equitably. We do this by partnering with governments, foundations, healthcare delivery systems, academic institutions, and so on, to try to bring about improvements in health and healthcare; as a not-for-profit organisation, we are very purpose-driven and mission-focused. We have three key priority areas including safety and effectiveness, which is about avoiding patient harm and ensuring care delivers on its promise to patients; equity, which is about ensuring that these improvements can benefit everyone and not simply those who can afford it or are otherwise systematically included; and finally, systems resilience which is about making sure healthcare systems can navigate future pandemics, challenges related to climate change, and the current challenges of austerity, the healthcare workforce, waiting lists, and so on.
As a response to the workforce crisis, countries are relying increasingly on the international nursing supply to meet their workforce needs, why is this?
This is a global challenge, but it is not a new challenge. We use the phrase ‘every system is perfectly designed to get the result that it gets’ and in healthcare, we have designed a system that is attracting fewer and fewer people, that is designed in a very complex way, and is making work, in many cases, harder than it needs to be. We cannot take away all the complexity, but we can be better at designing systems to make the job simpler for staff. The level of pay is also a variable that is affecting the attractiveness of healthcare jobs – countries’ GDP expenditure on healthcare can vary greatly, even among high-income countries where, for example, the US spends two or three times as much on healthcare resources than other high-income countries.
What else could be done at a policy level to make the profession more attractive and ensure that staff are being suitably trained and looked after?
Number one is to ensure that the health and wellbeing of staff are prioritised in an explicit way and that actions are tangible and effective in a measurable manner. That has a visible effect on the attractiveness of working in healthcare. To give you one example, at IHI we developed a framework for ‘joy in work’; instead of developing a framework to stop burnout, which would have been framed using a negative lens, we decided to use joy in work and incorporate what we had learned through conversations with healthcare leaders within the industry, and leaders outside of the industry, who set staff wellbeing high on their priority list. The framework covers nine key domains including autonomy and control, physical and psychological safety, and participative management.
Ensuring that we design policies that become forcing functions to prioritise the wellbeing of staff in healthcare is a huge contributor to making the profession more attractive. The design of the career itself is also important; we need to assess the design of the professional curriculum and how relevant it is to today’s environment. We tend to be very traditional in our approach to the medical curriculum for nurses and other healthcare professions. However, it seems like the current trends of pedagogically attractive approaches mean people can graduate in a relatively short amount of time and earn a good salary which can be helpful.
Access opportunities for these careers is also a variable, both from a financial perspective, and an alternative paths perspective. There may be people who want to switch to another industry or career, perhaps later in life, so we need to make healthcare professions more accessible and facilitate suitable career pathways for them. Similarly, it might be beneficial to educate school students about possible careers in healthcare and therefore promote the profession early on.
How could the healthcare sector benefit from increased collaboration and communication between care providers? Would a centralised base of resources be useful?
In the context of workforce shortages, we find that one of the most evident opportunities is collaboration. There is a balance to be struck, of course, between a sense of belonging (to an organisation) and building a culture that nurtures itself, where people nurture each other. Part of the collaboration at the organisational level could be framed as a solution that starts in either cities or regions where it makes sense geographically for people to be able to move between organisations, and this, in turn, could address healthcare workforce shortages. For instance, larger cities with high population density (London and the like) tend to have highly competitive healthcare markets where people have many job options. Can you imagine if the healthcare workforce had the flexibility to do their jobs across providers in a city or a region?
There are also new models of care emerging in integrated services efforts – designed and delivered by multidisciplinary teams in community and primary care settings – therapists, GPs, paramedics, and nurses all working to achieve better outcomes for their communities. Effective collaboration is not easy, and requires protected time and support to establish, but where this model has been embraced there seems to be a broader and stronger sense of partnership and support working where professional disciplines feel equal partners in the care of their community and can contribute to each other’s work experience and make sure patients get what they need, when they need it.
The pandemic exacerbated healthcare inequities; how do we tackle inequities across the health system?
The pandemic shone a light on the inequalities that have existed historically; we knew about them, but we never paid much attention. Equity is like the orphan child of the quality dimensions. When you think about how we have framed quality over the last 20 years, we have done a lot on safety, a lot on person-centred care, efficiency, effectiveness, and timeliness, but much less on equity. And it is important to clarify – we tend to frame equality as the challenge to be solved, but there is a precursor to equality, which is equity. You cannot pretend that you can provide equal access to healthcare professions for the entire population when we know that minority populations have worse school outcomes, and hence, a more challenging path to accessing a career in healthcare. If the starting point is different there is no point in being equal, you have to be equitable and proactively (and disproportionately) support those from minority or vulnerable populations, those who have historically been left behind. The pandemic highlighted those gaps through mortality data of healthcare staff and the general population as well as through vaccination access data.
We are more mindful now in the healthcare sector about the equity gaps that we need to close, but we need an unprecedented level of targeted and disproportionate action (on issues such as racism). One of the first steps is to ensure that equity is being proactively addressed in the early design of any intervention; it is an imperative variable that must be considered in the measurement of any health and healthcare improvement effort. There are different dimensions to consider including organisational (including staff diversity, how we behave with each other, leadership progression opportunities, etc.); clinical (access, treatment, and outcome); and population health (social determinants of health and the like) – how we address and target those that have historically been left behind will be key to making real progress.
Are there any examples of positive interventions to help with meeting the needs of the workforce that you could mention?
These are complex challenges and hence, there is not a single silver bullet. Action is needed urgently at several levels. At IHI, and just to illustrate one example, we have experienced a lot of success through partnering with big healthcare organisations – anywhere between five thousand and twenty thousand employees – who have committed to a relatively simple approach using the ‘joy in work’ framework. It invites two fundamental questions at team level across the organisation: ‘what makes a good day for you?’ and ‘what are the pebbles in your shoes?’ By understanding the themes that come to light through the dialogues that are generated, teams can start to develop a sense of what they can do more of, and what they choose to try to improve.
Using improvement tools and methods to test solutions, measure and learn, helps teams translate their ideas into daily work. We have worked with organisations in several countries using this approach, both as single institutions and across institutions that are collaborating. In addition to improving joy in work, in many cases, issues such as staff turnover and retention improve, as well as psychological safety and consequently, adverse events. An approach that invites the voices of everyone and the co-design and co-production of local solutions for local challenges shifts the balance of power and provides opportunities to learn both locally, across teams, and across the entire organisation. A simple example of a challenge that will surely require action at many more levels, and by many more actors. I remain optimistic based on the wisdom, commitment and dedication of those who work in health and healthcare, and their ingenuity to solve complex, wicked issues such as the healthcare workforce challenges we face today.