Health Care Providers Are Hiring the Wrong People
In healthcare hiring there have long been strong prejudices about race, class and educational attainment. Many of our conventions come from an era when healthcare was delivered primarily by doctors and nurses with elite training whose success depended mostly on content expertise. This paradigm is outdated; we now know that social, behavioral and relational factors are critical drivers of health. Thus, the new healthcare workforce needs more than biomedical knowledge; it needs diverse, empathetic team players at all levels who can support patients holistically. There has been little focus on hiring healthcare professionals with the traits needed to succeed in this new reality. This article offers an approach to finding, hiring, and retaining the diverse array of people needed to deliver the outcomes patients and provider organizations now expect.
In his 2004 bestseller, "Moneyball," Michael Lewis wrote "What begins as a failure of the imagination ends as a market inefficiency: when you rule out an entire class of people from doing a job simply by their appearance, you are less likely to find the best person for the job." Lewis's protagonist, Oakland A's General Manager Billy Beane, disrupted the process of hiring baseball players. Beane realized that scouts let unconscious biases blind them to individuals who generate the very outcome their teams need - runs. Undeterred by scouting convention, Beane pursued players like Chad Bradford, despite his "funny-looking" form. Bradford and the A's went on to a 20-game winning streak.
In healthcare, we are overdue for a "Moneyball" revolution. The shift towards value-based payment has made it clear that our system needs to do a better job generating outcomes that matter to patients - a positive health-care experience, improved health, and good quality of life. But healthcare's current hiring practices can inhibit efforts to achieve this goal. We may not have a bias against people with a funny throw, but we have strong prejudices about race, class and educational attainment. Many of our conventions come from an era when healthcare was delivered primarily by doctors and nurses with elite training whose success depended mostly on content expertise. This paradigm is outdated; we now know that social, behavioral and relational factors - like social support, lifestyle, diet and even a patient's relationship with her healthcare team - are critical drivers of health. Thus, the new healthcare workforce needs more than biomedical knowledge; it needs empathetic team players at all levels who can support patients holistically.
There has been little focus on hiring healthcare professionals with the traits needed to succeed in this new reality. With few exceptions, most organizations focus on training staff on competencies - from teamwork to cultural sensitivity - once they are already hired and hope the lessons stick. Healthcare's failure to invest in hiring for the full spectrum of traits needed has resulted in a workforce that isn't optimized for the job, and contributes to high turnover rates - 20.6% according to a recent survey.
In this article, we offer an approach to finding, hiring, and retaining the diverse array of people needed to deliver the outcomes patients and provider organizations now expect. Our recommendations are based on a review of literature and interviews with human resource experts and organizational leaders within and outside of healthcare. We also draw from our experiences at the University of Pennsylvania's IMPaCT program, where we have developed an innovative approach to hiring community health workers, a rapidly growing segment of the healthcare workforce. Our approach has resulted in a turnover rate of 1.7% compared with an industry standard of 50-77% per year. And indeed the people we've hired achieve results: multiple randomized controlled trials demonstrated that our CHWs have helped improve health and quality while reducing hospital days by 65%.
Here are four steps healthcare organizations can take to build a diverse workforce that produces valuable outcomes.Match hiring to the problems you need to solve
The first step is to understand what the workforce needs to do to achieve desired outcomes. What helps people become and stay healthy - especially those who are at the greatest risk for poor health outcomes? When we began designing the IMPaCT community health worker program, we asked thousands of high-risk patients these questions at the bedside, on porches, and in shelters. We analyzed the interviews and made a list of barriers patients were facing. For each barrier, we brainstormed a potential solution. Next, we listed the attributes that a worker would need in order to execute these solutions. We went through our patients' perspectives row by row, and created a three-page design map. Attributes like community membership and altruism rose to the top of our wish list for new hires. Just as important were the attributes that, surprisingly, were missing from our list - college and graduate degrees, or even previous clinical training. In the case of community health workers, some of these qualifications were irrelevant, others potentially counterproductive because they could create social distance from patients. (Sometimes a community health worker with real life experience but no college degree can help certain patients more than a highly credentialed colleague.)
Sample rows from a design map illustrate how to link barriers to solutions and the staff attributes needed to address them.
Doctors and nurses mean well, but "don't understand what it's like in the real world."
Provide support from a community health worker with shared life experience.
- Has a similar cultural and socioeconomic background as the patient. t
- Is a natural, innately altruistic helper.
Patients feel "talked at" and judged by healthcare professionals.
Have the community health worker get to know the patient by conducting an open-ended, strengths-based interview.
- Listens more and talks less. t
- Is non-judgmental.
Source: Elena Butler and Shreya Kangovi
Our process illustrates a basic principle: understand the problems you are trying to solve and hire the workers who can solve them, leaving aside personal and industry biases. Writing in HBR, Patty McCord described how she used this principle to grow Netflix as Chief Talent Officer. Healthcare leaders, including the Robert Wood Johnson Foundation and Academy Health, are beginning to use similar human-centered design paradigms to transform the field of healthcare research, including a reimagining of workforce.Know where to look
Once an organization knows who it wants, where should it look? Traditional provider organizations typically advertise job opportunities on their - often cumbersome - employment websites, or other job marketing sites. The problem with this approach is that it can perpetuate systematic class-based biases by creating barriers to entry for people with limited digital access or savvy, constraining applicant pools.
The alternative to "one size fits all" recruitment is to target efforts to the traits an organization is seeking. For example, when Enterprise, the largest car rental company in the world, realized they needed to hire team players, it looked for them on actual teams, recruiting newly graduated student athletes. Likewise, once we identified altruism as a key trait for community health workers, we sought out natural helpers by circulating job descriptions through YMCAs, soup kitchens and block captain associations. This approach yielded far more applicants who were suited for success in the role.Use the right assessment tools
Resumes, diplomas and training certificates are commonly evaluated credentials health care organizations use to assess candidates. While these do reflect an applicant's training and clinical skills, they shed little light on personality traits or attitudes. After eliminating applicants who don't have the legally required credentials, providers should consider multimodal tests that assess personality traits or aptitudes that predict of job performance, keeping in mind the legal, ethical and business implications of psychometric testing in hiring.
These types of multimodal assessments are starting to emerge in healthcare hiring. For example, innovators like Iora Health make a clear distinction between assessing traits versus skills; when hiring clinic receptionists, for instance, they are careful to assess applicants for a positive attitude and instinctive helpfulness, which is not reflected on a resume and often is challenging to impart through training. " We recruit for attitude and train for skill," explains Iora Founder Rushika Fernandopulle.
At IMPaCT, we hold informational "meet and greets" so that we can identify good listeners who make their peers comfortable, and deprioritize candidates who monopolize conversation. Boston Medical Center shows nurse care manager and community health worker applicants a documentary on supervised injection sites for opioid users, followed by a group discussion to gauge the candidates' receptivity to working with patients struggling with substance use. Some medical schools are beginning to assess traits such as empathy as part of their holistic admissions process. The right assessment tools enable organizations to evaluate traits beyond credentials and technical expertise that are meaningful drivers of outcomes - things like a service orientation, empathy, and an openness to people of diverse cultures, lifestyles, and socioeconomic backgrounds.Consider human resources a leadership function
Former Netflix Chief Talent Officer Patty McCord criticizes organizational leaders who view human resource management as a peripheral function. We likewise believe that the most effective hiring happens when leaders are deeply involved with the all aspects of the process because they have a unique sense of the organization's needs and the culture they aspire to.
In the early days of Amazon, Jeff Bezos interviewed every candidate himself. In our organization, the chief operating officer still sits in on most community health worker job interviews. This approach is resource-intensive. But it is the best way, we've found, to create the team we need to deliver the outcomes patients seek. It has the added benefit of dramatically improving retention and organizational stability, which benefits staff, patients, and the organization at large.
As healthcare shifts from clinician-dominated, medical-competency work to a team-based practice addressing the needs of whole patients and communities, hiring strategies need to shift as well. By stripping away hiring biases and focusing on the things that mattered for winning, the Oakland A's systematically identified talent that everyone else overlooked. Likewise, by redesigning hiring practices, healthcare leaders can hire high-performing people whose talents may be missed by traditional recruitment and evaluation approaches. Disrupting hiring practices and human resource policies is difficult work, but it will yield home runs for healthcare organizations and patients.