They’re normally caused by forces such as economic recessions or recoveries and — on a smaller-scale — influences such as strong influenza seasons and seasonal trauma rates. One example: The recession that ran roughly from 2007 to 2009 led to large drops in volume due to its strong economic impact on consumers. And then, not long after the economy began to recover, the fast growth in high-deductible health plans prompted drops in healthcare utilization that further reduced volumes.

As healthcare utilization and spending dropped, a lot of people began to wonder if we’d finally turned the tide on rapid growth in volumes and costs. But another force took effect that pushed the pendulum in the other direction: In late 2014 the Affordable Care Act created a new marketplace for the uninsured and gave subsidies to roughly 8 million people nationwide help them buy insurance.

Some of the newly insured had pent-up demand for healthcare — they’d had medical issues they wanted to get addressed, but they hadn’t sought care since they didn’t have insurance. So as soon as their insurance coverage took effect in April 2014, these new ACA enrollees came in for care. They used dramatically more healthcare than other people with insurance, and the higher utilization rates they initiated have continued, with some ebbs and flows in volumes and causes, up until today. At some point, this pent-up demand will be satisfied and volumes will return to a more normal utilization pattern, but for now volumes are very strong.

At Intermountain Medical Center in Murray, Utah, these big swings in volumes challenged our ability to staff our units, which resulted in some staff burnout and higher turnover. To help the hospital’s administrative staff understand all of the issues and concerns, the staff met with department managers to talk in small groups of eight to 10 people. The results of these conversations were compiled and major issues were identified.

Some of the areas of concern were:

• The workload felt overwhelming; employees felt fatigued.
• The hiring process was too cumbersome and time-consuming and we were constantly understaffed.
• Volume changes weren’t adequately understood ahead of time, which left people unprepared for surges.
• Employees didn’t feel valued; they didn’t feel like their opinions counted.
• Employees felt there wasn’t adequate communication.

The administrative staff developed an active plan to address these areas of concern. The plan included the following elements:

1. While administrative rounding had always been a part of Intermountain Medical Center’s culture, administrators felt the process could be improved. A more formal structure was adopted to improve rounding frequency and effectiveness, along with improved guidelines to help administrators and other leaders share information and concerns.
2. We created an enhanced communication plan, which includes these tools:
   
   • A monthly manager email titled “Need to Know” that shares important information in a concise, easy-to-read format.
   • An email series of videos to all employees called “Flagship Updates,” which provide brief recaps of major issues at the hospital.
   • Implementation of a Grassroots Engagement Council, or GET Team, which partners with departments across Intermountain Medical Center to invite input and ideas to help us increase open, two-way communication and enhance our overall commitment to extraordinary care.
   • Formation of a Management Advisory Council that meets regularly and helps keep open communication flowing between administration and managers. The council also helps managers do a better job of listening to frontline staff and keeping them informed.
3. Enhanced opportunities to decrease managers’ workloads by:
   
   • Completing a “meeting review” to find redundant or unnecessary meetings that could be reduced or eliminated.
   • Making a commitment to be balanced in goal-setting, which helps us hold people accountable for important initiatives without overburdening them with unrealistic expectations.
4. Improving our recruiting, hiring, and retention processes.
   
   • Reducing the time it took from when we recruit new employees to when we hire them — and improved the onboarding process and the first-year support we offer to new members of our team.
   • Working with Management Engineering to evaluate the causes for gaps between when an employee terminated and when a replacement was hired, trained, and was ready to work independently. We discovered that for the larger departments, having a few people in the hiring pipeline before the need for new staff arose helped close the gap between termination and replacement and didn’t create higher staffing costs.
5. Working harder to track changes in health plan growth, plan designs, economic pressures, and a myriad of other things to try and better predict volume swings.

All of these efforts have created an improved environment for staff and management. While we still have challenges with the ever-changing, dynamic world of healthcare volumes, our employee engagement has improved significantly — and it’s helping us maintain and improve our success in patient satisfaction and clinical quality.