Troy Clark, President & CEO of the New Mexico Hospital Association: Growing Your Own Healthcare Workforce

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

We’ve covered many angles of the healthcare workforce on this podcast, and today we’re going to focus on the perspective of one of the largest actors in the space: hospitals and health systems. With us to detail the workforce challenges and opportunities facing them — and what ideas and solutions are emerging ­from them — is Troy Clark, president and CEO of the New Mexico Hospital Association. In that role, Troy leads advocacy efforts with state leaders on behalf of his forty-seven member organizations and fosters collaboration with hospitals throughout his state to promote the improvement of health amongst the citizens of New Mexico.

Troy has spent over two decades in healthcare in both operational and financial roles, as well as working in for-profit and not-for-profit academic environments. I met Troy in April when I delivered a keynote at the national convening of the non-profit organization Comagine Health and its one hundred members. I spoke on the best practices outlined in my book — also by the name of WorkforceRx — and how Futuro Health put those best practices in action to address allied health worker shortages. Many of those concepts resonated with what he observed independently.

So, Troy, I’m so happy you are able to join us today to continue our conversation.

Troy Clark: Thank you, Van. It’s a pleasure for me to continue that conversation because it was, I think, a breath of fresh air or a nice introduction to someone who has actually put into place some of the thoughts and hopes that we’ve been discussing here in New Mexico.

Van: Well, I hope during our podcast you’re going to be able to share some of those hopes and thoughts. Just to set the table, please start by telling us more about what a hospital association does for its members and fill us in on who your members are?

Troy: So, as a hospital association, we really represent the advocacy efforts for our members. We don’t have operational responsibilities for them, but we work on their behalf on legislation, regulation, and public perception to advocate to improve the health and healthcare facilities throughout our state.

Among our forty-seven members, we’ve got ten that are post-acute — rehabilitation facilities, behavioral health facilities, long-term acute care facilities — and then the other thirty-seven members are acute care facilities, much akin to what most people picture when they see that blue “H” sign on the road, where there’s an emergency room, maybe surgery or labor and delivery. An acute care setting.

In our state, of those thirty-seven, we’ve got twenty-six of our hospitals that are very rural. Our largest city, Albuquerque, has about 800,000 residents. So, while an urban area, it’s a very small urban area. We’ve got five different hospitals plus the Veterans Administration facility here in Albuquerque.

We are the fifth largest geographic state. Outside of Albuquerque, we’ve got the remaining 1.2 million people spread throughout the rest of that state, so we have very small communities, 3,000-5,000 people, that may have hospitals who only have an emergency room all the way up to facilities outside of Albuquerque that have oncology, have surgery, have cardiology…some pretty well-rounded facilities as far as scope of service. We also have our Level 1 Trauma Center here in Albuquerque with a couple other large facilities that provide the care for our state.

Van: Well, that must make for an interesting conversation when you gather the mix of types of facilities and urban versus rural. So, tell me about these forty-seven members. When it comes to workforce issues, what are the top concerns that often come out?

Troy: You know, it’s interesting. We’re preparing here for our annual strategic planning session where we involve all of our members. It’s different than many other associations and companies whose strategic planning is really a board function. That is true within New Mexico and our hospital association as well, but at the early stage, we involve all of our hospital members in the process and then we hand it to the board to make the final decisions on those strategies.

We just completed a poll of all of our members as preparatory work for this, and the number one issue far and away for our forty-seven members is workforce. As we polled the members on those areas where they felt the hospital association could have an impact, only two of the forty-seven members felt like this was an area of impact. Having talked to my board and my executive leaders, there’s a perception of what we’ve done in the past that really the hospital association didn’t have a role in trying to solve the workforce problem. I agree with that, and I think that’s why you see it’s our number one problem for our hospitals, but only two felt like it was an issue that our hospital association could address.

That goes back to our role working with the state to try and increase funding to our centers of higher education to maximize the pipeline or the throughput of the production of a skilled workforce. While we believe we have to continue that, the rate of change that those efforts alone can make is not enough to meet up with the demand that we have today. So, we have to find ways to augment what they are doing and continue that work that we did in the past. As we look to the future, we’re asking ourselves how do we augment that to accelerate that production of the skill sets that we need throughout our hospitals?

Van: In a similar vein, when I was executive vice chancellor of the California Community Colleges, there was a manufacturing trade association, and the head of that association would go around and have meetings with members. She wanted to talk about savings on electricity and energy as the primary topic, but the members kept bringing up workforce. Finally she said, “I gave up. Workforce had to become a part of my agenda as a state organization.” So, I think your pain is shared by other state organizations.

Troy: It is. The pandemic has made our workforce situation worse, but we really had a deficit in our workforce skill set across the country before the pandemic. So, when there was a peak in increased demand for healthcare skill sets across the country, you no longer could beg, borrow and steal to hire on a temporary basis to move to where the needs were, because everybody had needs and there was no excess anywhere.

It’s interesting you use that analogy to the manufacturing environment. What got me headed down this path is that a year and a half ago, I joined our workforce connections board here in central New Mexico really with the idea that we have to do something more. I know there’s federal funding that comes into these workforce connections boards, but I don’t see it ending up in healthcare. I don’t see any output result. Why? I joined the board to find that out and got connected or made aware of a successful situation in Texas where transportation and distribution had done something similar to what I was thinking of: how do you do something collaboratively to leverage the federal dollars with the existing higher education and state dollars and industry input to really produce above what is currently being produced and getting everybody working collaboratively on that?

I got really excited until I thought, “That’s not in healthcare. How do I get this mindset to take something from transportation and distribution over to healthcare?” Lo and behold, about three weeks later, I’m at Comagine Health and everything you said resonated and I said, “Here’s someone who has taken a connection of what I’ve just heard about in the transportation and distribution sector and made it work in healthcare with allied health professionals.” I immediately cornered you at the end of your meeting and didn’t let you out of the room until I twisted your arm and said, “We’ve got to talk more.”

Van: Troy, one of the things I observed in the healthcare sector is that many of the hospital systems are very competitive with each other. What do you think it’ll be like to seek collaboration amongst organizations that are usually competitors?

Troy: I just had this conversation as I’m preparing and cultivating our CEOs to come to this strategic planning session that I told you about. I think the reason the poll came back with workforce being number one on the issues, but dead last in what we think the hospital association can deal with, is because we have seen ourselves as competitors. The mindset has been we have to out-recruit employees from either our competitors within the town, our competitors within the state, our competitors within the nation, or even now, internationally. We have this limited workforce that we’re all fighting for and our history has been, am I a better recruiter or not? Those who are better recruiters and retainers have a better workforce situation than the others.

Yet, what we learned and succeeded at very well in New Mexico during the pandemic was that when we collaborate, we can still compete and we will all win better. So, I’ve got a mindset amongst my CEOs right now that I hope we can build upon. We were able to succeed within the COVID era pandemic response, and we have one hundred percent agreement that we would have all been in trouble had we not collaborated. We’ll get together around the table and say, “Here’s how you responded to the poll and only two of you felt that there was a role the hospital association could play.”  When it comes to trying to out-recruit or steal business one from another, that’s really the wrong place for me as an association member to be. I’m trying to collaborate my members together.

You mentioned earlier the natural tensions of for-profit vs. not-for-profit, academic vs. urban…all different kinds of natural tensions that are there, but I need them to think outside the boxes. This is an area they’ve never collaborated on. So, if we are to present to them an idea where collaboration has worked, does that open their mindset? If we took that poll again, my hope at the end of this is the result would be forty-seven out of forty-seven saying, “You know what, I think there is a role the hospital association can play in trying to get us to collaborate and bring in the right partners to make something successful in an area where we are naturally, throughout all of our careers, are just used to competing.”

Van: Changing that mindset will be so valuable in terms of taking a different approach. Troy, interpret for me, when these CEOs talk about their workforce pain points, what are the words that they use?

Troy: “Unavailable” and “depressing” are two words that really come up. “Challenging” is another. This morning on a call with our finance committee, I heard about the upward pressure on salaries and the continued pressure for finding talent — let alone to get that talent to sign on with them — but I also heard about not having enough workforce. Interestingly, over the past six months, we’ve seen a shift where all of the conversation in New Mexico prior to six months ago was around nurses and physicians. Well, we’ve been in a nurse shortage in this country and in New Mexico for decades. But now I hear more that there is just as much difficulty with radiation technologists, I hear more about the ultrasound technicians, I hear more about the certified nurse assistants, I hear more about the respiratory therapists.

In fact, this morning I had a moment of excitement from one of our CEOs who said, “I finally have my first hired physical therapist starting next week. We’ve been without a physical therapist for over four months.”  They couldn’t even find an agency physical therapist to come in.

Van: Not even a temporary one.

Troy: Not even a temporary agency or contract labor to come in to fill their needs, and this is a hospital that probably has a demand of eight to ten physical therapists. And so, this mindset in New Mexico has moved beyond nurses and doctors. We still need to fill those positions, but we have been grooming and seeding the thoughts with our members that we have to grow our own. We will continue to recruit from all places — whether that’s outside the state, outside the country or within the state — but we have to create more because New Mexico is not positioned to win in the out-recruiting game. We’ve got a number of challenges within our state that don’t make us the more appealing choice when it comes up against many other states. So, we have to find those people who already have a love for New Mexico that live here and find them the opportunities to get the training so they can stay and be productive suppliers of health care services in their communities, especially in our rural areas.

Van: Well, of course, everything that you’re laying out is music to my ears because that’s the work that we’re doing right now, specifically growing the allied health workforce from diverse communities. Now, what is the situation with the rural hospitals? Are their pain points different from what you hear otherwise?

Troy: You know, they really are not. As we look at them individually, maybe one is having a more difficult time with physical therapy, somebody else with respiratory therapy, somebody else with surgical nurses, but the pain points are the same. They are recognizing that they don’t have a permanent workforce. Then on top of it, when they get a temporary workforce, if they are able to convince them to stay and become permanent employees, the length of time they stay is usually two to three years and they move on.

We commissioned a study about four years ago around physicians — we’ve not done it around any other specialty — but it really laid the groundwork for what we saw. In the state of New Mexico, if we did a great job recruiting a physician who did not grow up in New Mexico, didn’t go to medical school or do residency here, but we recruited them and brought them to a location in New Mexico, on average, they stay 4.2 years. If we are able to find someone who didn’t grow up in New Mexico, but did their medical school or residency here and we do a great job of recruiting them, they stay on average 7.6 years. But if we find someone who grew up in New Mexico and did their medical school or residency training in here and we recruit them to stay, they stay on average 17.3 years.

What a difference if you are only recruiting for a position every seventeen years versus every four years. It makes the biggest difference in our rural areas. Our rural hospitals average between ten and twelve percent of the GDP of their communities. If they lose health care from their communities, if their hospitals have to close, it is a nail in the coffin for the economic viability of that community. We’ve seen that in communities that have gone from community sizes of 8,000, they lose their hospital, they’re below 5,000 within a couple years. It’s the economic engine in these small communities. And yet, we suffer from what is unaffectionately termed “brain drain.”

Our children are choosing to go to other states when they get their training and find employment. We’re having a hard time keeping them. Many times in our small rural areas, that’s because they don’t have access to education in their hometowns and they don’t have the opportunity to serve in their hometowns. When they leave to go get their education elsewhere, they stay elsewhere. So, we look for efforts on how to create situations where they can grow up in these small rural towns, gain their education through a tele-learning experience, go on site for the few weeks that they have to — depending on what their specialty is — but do their shadowing and their rotations within their local hospital and then stay. Who knows their community any better than they do? They grew up there.

From a diversity and equity of delivery of care perspective, what an asset to that community. From an economic standpoint, the hospital doesn’t have to worry about workforce that’s turning over every four years and/or paying contract or temporary labor rates. They have somebody local, and they have someone who’s committed to improve on the quality front because it’s the community they live in and that they care about.  Not to be negative towards agency or temporary contract labor, but they’re there for twelve to thirteen weeks. Quality is a lifetime journey. They don’t engage in quality improvement processes because they’re not going to be there that long. And so, the hospital ends up suffering and the community ends up suffering from a quality perspective because they can’t focus on continuous quality improvement.

There’s a lot of different reasons we feel growing our own, to augment the workforce that’s already being created, is so essential from an economic standpoint for our communities as well as a quality and viability standpoint, and quite frankly, a respecting of the diversity and equity and being inclusive of cultures within our communities. If you know New Mexico well, we are a very diverse state. We have a wide variety of cultures between Hispanics and Native Americans and different religious sectors. There’s a lot of different cultural uniquenesses. What exists in one quarter of our state is totally different in another.

Van: You referenced this a little bit, but let me ask you, what is your assessment of the higher education infrastructure for your rural members and can it keep pace or can it deliver on the volume of requests?

Troy: The current makeup is that most of our mid-sized cities have community colleges or junior colleges with some form of health care programs. Most of our smaller communities don’t.  To give you some perspective…because of our geographic size, we have four communities in our state that have more than one hospital: Santa Fe, Las Cruces, Albuquerque, and Roswell. Everywhere else you have a single hospital and most of those hospitals are fifty to one hundred miles apart. This is not like many parts of our country where towns are ten or fifteen miles apart and each town has their own hospital. This is a very different geographic makeup. You’re talking about communities that may have a 100 to one 120-mile drive to get to the community college that’s closest to them.

We’ve also got two major universities in the University of New Mexico and New Mexico State University. I think our biggest challenge with our biggest universities is that they have a structure and a mindset that is built for a specific purpose and their ability to change and grow is not quick enough. It is a slow process. So, we have focused our efforts really on our smaller centers of higher education which are more nimble. However, there’s not consistency among those. We have some of those community colleges and junior colleges who are much more advanced down the spectrum of moving to tele-learning opportunities. We have some that are still very much in-person, in-class, so you relocate to the town they’re in, go through your education, and go home.

Quite frankly, we’re trying to change that mindset and encourage that change but leverage the opportunity for those who are already ahead on the curve when it comes down to that tele-health learning opportunity. You could be a town 300 miles away and accessing care tele-learning because it doesn’t matter. You may not be getting your education opportunity from the school that is closest to you. So, that helps us on two fronts. One, leveraging those who are already down that path of technology but two, leveraging that path to where programs may be. Maybe the school closest to you doesn’t have a respiratory therapy program, so let’s get you connected by tele-learning to the school on the other side of the state that does. Or maybe it’s a CNA program and working very closely with them to also work with our schools.

As part of that, I think the role I tend to talk a lot about is their relationships with the high schools and getting dual eligible credits so kids come out and can be certified very quickly, but even that’s very old school thinking that I even have to get out of my mind because there is a large portion of our population that would be what they define as the non-traditional student — the twenty-five- to forty-five-year-old — who isn’t in that group. Obviously, they’re not in high school so we need to provide the opportunities and awareness for them to be able to select a healthcare career as well.

Van: To be able to transition adults into these good careers.

Troy: Correct.

Van: So, in the field of healthcare, there is also the element of clinicals. The employer wants the learner to have spent some time practicing the skills, especially on live patients. That often is a bottleneck area. Have you seen any creative solutions either within the state or maybe at some of your peer associations?

Troy: It absolutely is a bottleneck. In nursing, we call them clinical rotations. In physician work, we call them residencies. In other industries, they often call them apprenticeships, right? It’s that hands-on experience with real life patients, but being proctored or mentored by someone with experience so you get the live experience but you don’t have the risks that come with being inexperienced. Unfortunately, what happens in most parts of the country, including our part, is higher education is limited by the number of proctors and mentors that they have to place on site, so oftentimes, these clinical rotations are done on Tuesday, Wednesday, and Thursday mornings from 7 a.m. to 3:30 p.m. If you go into hospitals that work with their centers of higher education, quite often that’s when you will see students.

Well, having a proctor or a mentor who has two or three students assigned to them, you can just see the workload and the experience they get becomes diluted and if you add a fourth or a fifth student, you’re standing and watching an inexperienced person do something and every fifth time you get a chance. So, we have pushed and said, you know, hospitals operate twenty-four hours a day, seven days a week. We can increase the number of rotation slots Mondays, Fridays, Saturdays, Sundays, and evenings. There’s a lot of other times, but it takes the ability to have these proctors and mentors on site during those other hours.

In our last two legislative sessions, our efforts have been to increase funding to our centers of higher education with funds that are specifically designed to increase faculty salaries and facilitate the increase of mentorships and proctorships so that they can start to offer these opportunities on those other hours that we’ve got and to look to provide opportunities for helping subsidize the cost if we open up rotation slots in rural communities that don’t have centers of higher education. They would love to have students come through because one, it’s additional helping hands for them, but two, it’s an opportunity for them to interact with the students on more than just an interview basis to see who’s a good fit and to recruit them to come to their facilities and see what their town is like.

We’ve been successful in the last two years getting additional funding into our centers of higher education with the hope that that pays off. It’s a little too early to see as it comes through. The first year it was one-time funding. This year it got turned into permanent funding. Those are big steps that we’ve made to try and augment the existing centers of higher education.

Van: Oh, that’s outstanding work. Congratulations to your association.

Troy: Well, it’s a lot of work. Like I say, we now have to implement.

Van: What are you hearing from all of your peers specific to workforce, but also about how the future of care is shifting?

Troy: Well, in a good way that I agree with, but I don’t think it’s enough, I think my peers are seeing that in terms of the issues with workforce, we can’t just rely on trying to do better than what we did in the past. I grew up playing sports and I kind of make the analogy that this effort is much like a coach that stands on the side and just says, “do better.” Well, his team doesn’t know what to do, right? What do you mean? I’m already trying. So the coach needs to train them and guide them on the different things you can do.

Mostly what we see across the country is efforts right now in redesigning the care team makeup. We have a history of having a nurse assigned in an inpatient unit — depending on whether it’s intensive care or med/surg — from two to five patients and being supported by nurse assistants and calling in specialists from physical therapy or respiratory therapy when patients have needs. There’s a move now to say, how do we enable technology to maybe change that care team where there’s a nurse that deals with medications remotely in a hybrid type model to allow the RN on a floor to serve more patients, but have more certified nurse assistants dealing with answering of call bells, helping people use the restroom and all the other functions that happen?  Can we shift the care model team to match the disparity in what we have from a skilled trained workforce?  I think that’s an important component, but I fear that if that’s the only component that people move to, they’re going to still be left short- changed because we still won’t have enough nurses.

We’re over a hundred thousand nurses short in this country — that’s the estimate right now — which I believe is low. There are large numbers of shortages in other professions as well, so if you think about how do we react to this, we can’t just try and push more through the current sausage-making machine and expect to get enough output. We do have to change the care team model, but we also have to find new ways to get people interested and certified or licensed into all of the different positions, including nursing, allied health positions and our non-clinical positions. If you look outside the healthcare industry, I think every industry right now is talking about workforce shortages.

Van: That is true. What about value-based care or preventive care? What are you hearing there, Troy?

Troy: There’s lots of movement towards value-based care. There’s been efforts on this over many decades. It’s becoming a more popular buzzword, but it means a lot of different things. There are value-based care programs that are “shared savings” models that say, “Hey, let’s collaborate on this between a payer and a hospital and physician group so that if we reduce the cost of care by doing more preventative care or moving to a lower cost of care scenario, then we’ll share those savings with you.” Then it goes all the way over to the other side called “capitation” where a physician group and hospital take on full risk for the care and say, “You provide us a fixed fee amount and we will provide all of the care regardless of what it costs.”  The motivation, obviously, is to try and keep that cost below what they’re paid.

Quickly, I think one of the big challenges that’s out there right now — and we see it specifically in our state — is how do you implement value-based care programs and initiatives in rural areas? You don’t have a high enough population to take the actuarial results and the actuarial studies to direct new programs to try and lower that cost of care with low populations. You really need probably 25,000 to 50,000 people or more. I told you that many of our communities are 3,000 to 5,000. So, how do you seek for those benefits and invest in the infrastructure that it takes when you have such a small number and you don’t see the return?

Van: Now, I’m going to ask you the closing question which is, knowing all you know about the future of care and all of these trends that you’re seeing front and center, what advice would you give someone whose children or nieces and nephews are interested in moving into the healthcare field? What are the skill sets and education or experience that would position them well?

Troy: You know, I think this past few years has really been interesting on the perspective of healthcare and I think it’s sent some mixed messages to people out there — whether they’re young or whether they’re older — who are possibly interested in a healthcare career. If you look at the beginning phases of the pandemic, our healthcare workers were heroes. Many signs were put out in front of hospitals saying so. I remember in the first year of the pandemic, most of our hospitals had more local restaurants and people bringing in food than the workers could eat to try and sustain them and thank them for the efforts.

And then as, unfortunately, the pandemic went on and things became politicized, our healthcare workers saw the other side of the equation where they were quite often vilified. If somebody from healthcare represented something different than someone’s political feelings, all of a sudden they weren’t the hero anymore. Now they were the enemy or the antithesis of their political beliefs and treated them as such.  I think that caused people to look differently at healthcare careers. Is that something I want to go into or not?

I say that as a preface to make the point that at the core of healthcare is compassion and caring. Whether you work in the business office, whether you work in the maintenance department, whether you work in registration or if you work at the bedside as a clinician of any type, there’s compassion. People are not in the hospital because they want to be. They’re there because something’s not working right with their body or with their mind, and they have to be there. So, you have a need in the healthcare workforce, I believe, to start off with compassion.

Although I’ve never been a care provider, I’ve worked in hospitals, as you said, over two decades. My fondest memories are interacting with patients…the stories where a patient either directly communicates or through body language communicates, that “you were there for me when I needed you.” So, I think those individuals who have that desire for a human connection and compassion will be a good fit.

What I would say beyond that is bring us the skills and interests that you have and let us help develop them because there’s a lot of people that may not like bodily fluids and blood and disease and don’t want to be a physician or a nurse, but may want to be in healthcare to help people and could be in the business office, could be in the dietary area, could be in the maintenance area. Or, you could have some that maybe don’t want to deal with needles, but love to do ultrasound. There are so many different areas within healthcare that if you have that desire to be a caregiver, to be compassionate and caring, I think you should seek out and talk to people within healthcare. I guarantee you we can find an area that you would enjoy fitting in, and that can be everything from the accountant to the physician.

Van: Well, that’s a great way to end, Troy…issuing a call to action to invite everyone who is interested in a career where you can demonstrate compassion and the human connection. It’s so important to invite them into healthcare. We’ve appreciated so much you sharing all of your insights and advice today. Thank you so much for being with us.

Troy: It’s been my privilege. Thank you, Van, and I appreciate being in this work with you together.

Van: I look forward to that. We’re going to help your members grow their own right there in New Mexico. I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.