Help is wanted – desperately
On the National Association for Healthcare Quality (NAHQ) website, there are 770 current job listings for quality professionals. Move over to a more general job board, like LinkedIn, and a search for hospital and healthcare quality jobs in the United States can give you more than 17,000 listings — a couple thousand in the “mid-senior level” and a cool 800 from senior to executive level. There are 8,000 entry-level jobs listed. They are available in hospitals, health systems, and third-party payers. You can find quality jobs in pharmaceutical and medical device companies, large multispeciality clinics, and the smallest of rural hospitals.
This is not news to anyone working in the industry. It is taking months to fill positions, especially the more senior ones. L. Dale Harvey, MS, RN, a patient safety fellow and director of performance improvement at VCU Health System in Richmond, VA, says that she’s had some positions open for months.
“There’s a lot of work out there, and we have a very hard time filling positions,” she says. “Some of that is because of the shift of focus to patient safety and quality, and some of that is because the pool of candidates has varying skills and competency.”
Two positions have been open for six months, and one for two, she says. That’s a little anomalous because the two longer-open positions are newly created ones. “But we prefer to wait for great, not settle,” she says.
She runs into the problem of there being little standardization in skills in the profession. NAHQ has its certification program, but Harvey says that it is for the basics of quality. And the profession has changed so much in the last five years that a great mid-level candidate will need to demonstrate more than the CPHQ basics.
“The certification is based on a job analysis [survey] of currently practicing Healthcare Quality Professionals, so it reflects the current state of competencies needed,” says Mary Huddleston, RN, MHSE, CPHQ, FNAHQ, president of the National Association for Healthcare Quality and a quality professional working at a large health system hospital in St. Petersburg, FL. “The Competency Project we are currently working on is for competencies of the future, although admittedly the future is rapidly approaching.”
“We want a department with both a novice and experience mix, and are willing to look outside healthcare,” Harvey says. “We have hired from the finance and engineering industries to get people with the right values and culture.”
They cull applications and network — Harvey says networking usually gains the best recruits, although the ones who are clinicians sometimes have a misconception of the job. “Clinicians seem to think we work 8-4, Monday to Friday, and that we are off holidays. But we work 50 hours a week.” Harvey was talking to HPR on the day after Christmas from her office, where she was putting in a full day of work. “Quality works weekends and holidays. It’s not as easy as some people think.”
One of the big changes that has made hiring more difficult is the shift to more specialized skills needed in the typical quality department at a medium or large hospital. If it is not a small facility with just a couple of people, then there will be a division of labor, Harvey says. Some people will focus on data abstraction and analysis, some on project management, some on root cause analyses. “In nursing, everyone may be an RN, but some work in pediatrics, some in oncology. It’s the same with quality professionals.”
Different skill sets are required for each. “Most quality managers, a decade ago, were nurses who didn’t want to work at the bedside anymore,” Harvey says. “Now, the importance of the work means that this is a career choice. It’s a job people seek out from the beginning of their career, including physicians, which is new. They see quality as a career track. It’s different every season; the work constantly evolves. That makes it of interest to people who are afraid of being bored.”
Some quality improvement efforts have specific requirements, says Claire Davis, RN, CPHQ, director of quality at Middlesex Hospital in Middletown, CT. The National Surgical Quality Improvement Project (NSQIP) requires dedicated personnel. Other specializations that are new to quality include people who are specialists in high-reliability, core measures, risk management, patient experience, and primary disease certification.
“There are tons of open positions for every level of quality professional,” Davis says. “But the problem is, what they are looking for is a soup to nuts professional.”
That’s a step back in time to when the department handled Joint Commission surveys, safety, patient complaints, core measures, data abstraction, and risk management. Davis has nine people in her office, including 1.5 for NSQIP, one person for all quality and core measures for obstetrics and psychiatry, one person handling CMS and Joint Commission core measures, one person handling quality studies for medical staff, one handling external regulatory readiness — think surveys — and one doing safety and high reliability. Patient satisfaction and risk management are in other departments.
“You used to have a general surgeon who did everything,” Davis says. “Now surgery is specialized. So are we.”
The problem is that each of these specialists becomes limited by his or her experience. “There are few quality improvement managers who are full A-Z professionals now who can step into the director-level jobs and know all the pieces,” Davis says. She worries about succession planning in this kind of environment. “There are so many people looking for directors, but not a lot of people with the full scope of skills out there, and for those of us who came into the field in the 1980s, we are aging and thinking about retiring. Who will fill our shoes?”
Davis says she has one of her staff who has the requisite background, and although she tries to mentor as many of her staff as she can, “I can’t mentor all nine.”
The importance of integration
With specialization, integration becomes more important, says Huddleston. “You have to learn to collaborate and cooperate. People get sick and have babies and go on vacations, so understanding the other programs is a necessity.” Just because the skill sets of your data analytics person are different from those of your patient satisfaction staffer doesn’t mean they can’t work together on a project and learn from each other, she explains.
Davis’ method has been to rotate people among their main assignments. Everyone learns root-cause analysis, to respond to complaints, to deal with Medicare and Medicaid guidelines. This year, there was a special opportunity for learning that Davis appreciates, at least in hindsight. “We had six surveys this year — Magnet, Joint Commission, CMS and three specialty surveys,” she says. “I trained a subteam and put different people in different places for each survey. For one, a person might work with me on mitigating findings, for the next, that person might be the gopher. Everyone had a lot of really good experience in many areas.”
CPHQ certification is required, and she encourages staff to attain fellowship status, but she would, like Harvey, appreciate seeing more, expanded certifications.
Huddleston says NAHQ is working on that. This is the 40th anniversary of the organization, and the exam for the CPHQ credential is likely to change. It’s already undergone some transformation, Huddleston says, with the addition of patient safety questions when that topic became a big issue. But in the future the credential will be based on mastering concepts in six core competencies: health data analytics; population health and care transitions; patient safety; regulatory and accreditation; quality review and accountability; and performance and process improvement. The ones that excite her most are forward-looking, not responsive, predictive of future needs, Huddleston says: population health and care transitions, and data analytics. “We see them as a screaming need,” she says. “In my work personally, I see the data analytics piece as a particular need.”
In the end, Davis says, the goal is always to train someone who can take her job, and to encourage the people she trains to go out and climb the ladder like she did. But she worries about a middle gap at the director level.
“Those who have gone forward, who might have been doing this for 40 years, in a normal progression, would have become a vice president or something higher, but until 2000, after the Institute of Medicine report and the move tying quality to value, no one was really interested. No one outside quality wanted those mid-level jobs,” Davis says.
Positions are open
Now, quality is a major driver for healthcare and the financial well-being of hospitals. Positions at the higher level are open. The problem is that people who do not have experience in the quality trenches are applying for — and sometimes getting — those jobs. C-suite level positions for quality are going to physicians who may or may not have experience in quality, she says, and the people who have been doing this work for decades are being left out. She worries it may be demoralizing. “That’s why there is a shortage of directors. There is a lot of capability to move up, but there hasn’t, before now, been a lot of opportunity to move beyond a certain point. Lateral moves, particularly with relocation, aren’t worth it.”
That is changing, Huddleston says. Part of it is “making yourself indispensable.” She herself sits in the C-suite with the chief medical officer, chief financial officer, and chief human resources officer. “You have to prove your worth. You need to learn to lead and to influence people and make the business case for quality. I see my role as to see what’s coming, to keep the facility out of trouble by finding problems and fixing them. I have to keep us out of the bear trap.” Do that, she says, and quality will find its way to the top.
For more information on this story contact:
- L. Dale Harvey, M.S., RN, Patient Safety Fellow, Director, Performance Improvement, VCU Health System, Richmond, VA. Telephone: (804) 628-1131.
- Claire Davis, RN, CPHQ, Director of Quality, Middlesex Hospital, Middletown, Ct. Telephone: (860) 358-6337.
- Mary Huddleston, RN, MHSE, CPHQ, FNAHQ, President, National Association for Healthcare Quality, St. Petersburg, FL. Telephone: (847) 375-4720.