The pandemic and other challenges have left many healthcare organizations struggling to recruit and retain frontline healthcare workers.

In this episode of Healthcare Insider, Dr. John F. Di Capua, CEO of North American Partners in Anesthesia (NAPA), discusses the impact of these staffing challenges on providers and consumer access to care, describes how to foster a work environment that encourages clinicians to stay and grow at your organization, and explains why leaders must establish cultures that are inclusive for all.

Camille Baxter: Hello, and welcome to Healthcare Insider, a sponsored content podcast series from Modern Healthcare Custom Media. I'm your host, Camille Baxter. Today, we are speaking with Dr. John Di Capua, the CEO of North American Partners in Anesthesia, commonly known as NAPA. Dr. Di Capua is a trained anesthesiologist with fellowships in pain management and cardiothoracic anesthesia.

Dr. Di Capua is passionate about infusing a performance-based culture into healthcare and empowering clinicians to drive quality and operational improvements that support NAPA's Patients First, Partners Always philosophy. He is deeply involved in the issues of perioperative operational management and clinical staffing models, and lectures nationally on how anesthesia departments can provide quality and operational value to hospitals.

Before we dive in, we'd like to thank the sponsor of this episode, North American Partners in Anesthesia. NAPA is the nation's largest single specialty anesthesia and perioperative management company. Clinician-led since 1986, NAPA's 6,000 clinicians now serve 3.2 million patients annually at over 500 healthcare facilities in 20 states.

Today, we are talking to Dr. Di Capua about staffing challenges and what healthcare leaders can do to stabilize their clinical workforce and create optimal workplace cultures. Dr. Di Capua. Thank you so much for being here today.

Dr. John Di Capua: Thank you, Camille. It's a real pleasure to be here. Honestly, thank you to you and to Modern Healthcare for hosting these podcasts, because as I tell a lot of people, this is a unique time in my 40 years in healthcare, and it is so important to be able to get these kinds of communications out there for both the profession and to the communities at large. Thank you, it's a pleasure to be here.

Camille Baxter: You're welcome, and I'm excited to talk about our topic. Let's talk about those challenges. What are the stresses putting pressure on providers, and why does staffing keep turning up as the number one concern for CEOs?

Dr. John Di Capua: Well, I'll tackle the second part of that first. Why is it so important to hospital CEOs? Well, I think we take it for granted that in the United States, that if you have a condition that can be corrected or made better by surgery, that it's just going to get done. But just think about that statement. I mean, when we talk about some of the miracles of modern healthcare, the ability to do surgery to change someone's life is so impactful that it's important to hospital CEOs because that's part of their mission, to deliver care in their communities.

Now, as it turns out, it's also a major economic issue for most hospitals and ambulatory surgery centers. The way that healthcare reimbursement to hospitals and ambulatory surgery centers exist, they get paid disproportionately for doing procedures.

The inability to staff operating rooms that drive procedural volume has a major impact on hospitals' bottom line, who, many of which, are already struggling because of the other issues in healthcare. There's a lot of focus on staffing in the operating room.

Camille Baxter: With all of these challenges going on, how was this situation exacerbated by the pandemic?

Dr. John Di Capua: Well, the pandemic may have made it worse, and I'll talk about that in a second, but we've been predicting a supply and demand imbalance in perioperative services for years, because everyone knew that we were getting more demand. We have more humans on earth today and fortunately people are living longer. As longevity increases, we have a greater need to do surgery because people over 65 use surgery twice as much as people under 65.

Then there's a whole push by a lot of people, government, insurance companies, patients, surgeons, to move cases to ambulatory surgery centers. We're seeing a huge amount of resources being spent on building brand new operating rooms in the communities for outpatient care. We're also seeing an explosion in office-based care. All of that will continue.

Then you have medical innovation, medical innovations allowing us to do surgery on people that would've been denied before. Thank goodness that now, if you're in your 90s and you have a bad aortic valve, we actually can help you with that. As opposed to in the past, we would've said at 92, maybe it's not the best option. But today we can, that means we have yet another candidate to have procedures and anesthesia.

There's been this supply and demand imbalance developing over the, I would say, the past decade and everyone knew that it was coming. We didn't really train more people to keep up with the demand. The result of that is provider burnout. Our clinicians, nurses, what I'm telling you right now about anesthesia is equally important to our perioperative nurses.

People go into healthcare because they want to help the communities. When you live in the community in which you serve, just because someone says, "Well, I'm sorry, I need you to work harder," people just step up to the plate and they do what they need to do. Eventually, that taste its toll. We've had burnout issues developing, and there's been a lot written about burnout in healthcare.

In anesthesia, it's primarily due to the supply and demand imbalance. People are taking more call, they're not sleeping as much, they're staying later, they're missing important family functions. They're doing it because they feel connected to their colleagues and their communities, but at the end of the day, that's not sustainable and we're seeing people burn out.

On top of that, you've got some programs, like Medicare, is cutting reimbursements to anesthesia your providers. You've got no surprise billing laws that are saying, "Hey, we don't want to have patients get a surprise bill," but the untold story behind that legislation is it's a system that allows commercial insurance companies to bring down the medium reimbursement to clinicians. Imagine if you're a provider and you're in this world where you're working harder than you necessarily want to and they're telling you they're going to pay you less. Burnout hits really fast.

Then you have the pandemic, which creates anxiety, personal anxiety. If you put your head back in April of 2020, we had no idea where this was going to go. We didn't have enough PPE equipment to protect our people, so they went in like firefighters going into a burning building, putting in a lot of personal sacrifice and they had no idea where this was going to go. Some of our providers have medical conditions that put them at higher risk.

You've got burnout, lower reimbursement, anxiety, that leads to early retirement. Now, in anesthesia, we have a particular challenge because we have a bimodal distribution of our workforce. We have a lot of people, easily more than half, that are really close to retirement.

When you start adding these stresses, we are about to fall off a cliff. For the first time in this country, we're now starting to see that, due to nursing shortages, perioperative nursing, and anesthesia shortages, we're now starting to delay access to life-changing surgery.

That is only going to get worse, which is the reason why I like these podcasts, because we need to change something. Otherwise, this is going to get worse and you're going to start to see people, particularly in poorer and rural communities, have real access to healthcare problems.

You'll see people having to drive very long distances to find a place where they can actually schedule your surgery. We've never dealt with that in this country. We have a very expensive health system that at least provided access to most, it was never access for all, but it's going to get worse. That's just going to be a new thing for people this country to cope with.

There's a lot of attention in my industry about this. I think hospitals, whose economic engine is dictated by the operating room, are now starting to ask, what can we do about it?

Camille Baxter: Yeah, it's so important to better understand this. In this environment, with all of these things going on, how do you create a framework that provides clinicians workforce stability for their hospital and for ASC clients?

Dr. John Di Capua: Yeah. Well, the first thing you have to do is you've got to make the workforce understand that you really care about them and you want to listen to them. Just take what we did during the pandemic, we held very frequent town hall meetings, a lot of communication with our people. Because surgery was being shut down, or elective surgery was being shut down, there wasn't a lot of revenue to pay for services, and so a lot of our competitors or a lot of people in healthcare decided to cut salaries for clinicians in the middle of the pandemic. We thought that that would be a very bad move, and so we did not.

We did everything else to cut resources, to protect all that money and resource to give it to the clinicians who were going out and taking the risk in the front lines. A lot of us in executives, we didn't take salaries, we furloughed a lot of non-clinicians, but we kept all of our clinicians whole at a period where they were most anxious. In fact, we sent a separate message. We decided that this was a great time to recruit people who were anxious about the workforce. We hired more people during the pandemic than at any time in our history.

Alleviating fears and anxiety to make sure that people in healthcare understand that when they put themselves out there that you've got their back, that's really important, because when you're asking people to work harder and you're going to pay them less, that doesn't make sense in this country, particularly when you're dealing with high acuity services like we're talking about in the operating room.

We're very much people-centered, we ask our people through engagement surveys. We ask them, what would create the best possible work environment for you? The answers we get now are very different than what we got years ago. People now are looking for flexibility, they're looking for stability and they're looking for career opportunities.

What does it mean for flexibility? Well, flexibility in terms of work hours. People in different stages of their life want to work more or less. Early on, when you're trying to establish yourself in a community, you're willing to do that over time because you need to set your nest, you need to get that home, you need to bring your kids to that school system.

People are willing to work harder then, but then you want to spend more time on the soccer field and they want to work less. As clinicians, we were told never to talk about that, but we're human. People are saying, "Listen to me, I can't do that much work when I'm supposed to be doing important things with my family." They want the ability to go up and down in terms of their work commitment.

We, at NAPA, definitely understand that. We basically said, "Don't worry about it. We'll figure out the puzzle," but in our world, you can work full-time, with call on weekends or no call, or part-time, or you want to work one day a week. It doesn't matter, because at the end of the day, if you can create that flexibility for people, they'll stay with you throughout their career

It's also about I want to have interest in the work that I do. Sometimes I want to work in complex cases, but I can't do that all day long and every day of the week. Some days I want to work in a simple environment where we get to laugh a little bit more and we get to socialize a little bit more. That's why, at NAP, we have both footprints in complex hospitals, community, hospitals, ambulatory surgery centers and offices, because our people then get to move between in those environments as their careers dictate. That's one of the benefits of scale, is that you can create those environments so people don't have to leave your company to go and find a different path. They just stay in the same place and they just move along.

Stability. They want to know that they have a job today and the rug isn't going to be pulled out from under them. That's where scale comes into play, because when we think about what the government is doing in decreasing provider reimbursement, they're doing it to try to balance their Medicare budget. In my mind, that's the wrong place to go and attack spending. There's so much more waste in healthcare, that the providers are not the place you're really going to make a big dent, but they're the easy ones. They have the smallest voice because they don't have nearly the size and scale that hospital systems have or insurance companies have.

Our job is to create that scale for those providers, to be able to be a national voice. We only do anesthesia because we know that our customers really care about their operating room and we know that our clinicians want us to focus completely and utterly on the issues that they face. We, as a large scale company, we add advocate for them and we create that stability so that when

Medicare makes a change, their world doesn't end. We figure out how to make it all work somehow, by either becoming more efficient or balancing different kinds of contracts or advocating for support from our partners who desperately want the service. Whatever we do, we create stability in our workforce.

How do you do all of that, too? It's about leadership, and we invest a lot in leadership. We train our leaders with resources they never get in medical training, whether you're a nurse, a CRNA, or physician anesthesia provider. We know that they're important tools if you're going to create teams and if you're going to try and solve problems and create a healthy workforce. We invest in our leaders and make sure that they create the right environments. If you do those things, you have a chance at retaining your talent.

Camille Baxter: You've talked a lot about the type of support that you give to anesthesiologists as that anesthesia partner. Can you say a little more about that?

Dr. John Di Capua: People don't like to talk about this, but we have to talk about salary. You have to pay the market. It's the reason why we dared not touch provider income during the pandemic, we just thought it was wrong. But in the labor shortage, our providers are in so much demand that people are competing with each other and they're just driving up the market. As it changes, we as a company have to keep on top of what is the market in this region at any given point in time. We don't allow our people to come to us and say, "You're behind the times." We know what it is and we just do it.

The importance of leaders can't be understated. I would tell all people out there, whatever the system is, in the operating room, we deal with high stakes things, these are serious things that we do to people and most of the time they go well, but sometimes they don't and so it can be a pressure cooker, that's where you need to make sure that you've got the team communicating well with each other.

We invest a lot in teaching all our providers on proper communication, during normal times and stressful times. We actively give them tools. They may seem basic, but trust me when I tell you that not everybody has them natively. You've seen people who have good bedside manner and people that don't. Well, we insist on trying to teach everyone good bedside manner, because they need to talk to their surgical colleagues, their nursing, their colleagues. We teach communication.

Our leaders, they have to have the highest ethical standards. They have to be able to lead by example. We invest not only teaching our leaders through year-long educational programs, but we hold them accountable through their performance bonuses on meeting certain metrics. We're very driven about what it means to be a leader.

We hold you accountable for recruiting and retention, we hold you accountable for making sure the hospital knows why we're there and why we're a good service for them, we hold you accountable for getting good 360 reviews from the people that you lead. If there's a problem, we make a change, because we ask our people through engagement surveys all the time. We don't wait for people to say, "You should have asked me, but it's too late, I'm gone."

We fight on a national level on behalf of our anesthesia providers, we advocate for them. Things like the No Surprise Act is just not it, I think, for this country, the way it's currently written. It's good for protecting patients from surprise bills, but there's so much more to the No Surprise Act that a lot of people don't understand, and those things are very self-serving by some very large lobbyists.

I think we have to fight in order to get that back to a more even keel. I would urge all of healthcare to recognize what these things mean to our providers and to go out and join up and fight these issues.

Camille Baxter: Can you talk a little bit about what it means to be a destination of choice for all, and why should healthcare institutions adopt that mindset?

Dr. John Di Capua: This is something that's near and dear to me because I have, as an immigrant where Spanish is my first language and I grew up in a very different healthcare environment where it's very foreign to people in the United States where we have mostly Western medicine, but most of my care was not Western medicine. It was more typical of bodega-type medicine. Those beliefs are held very dear by a lot of people in the world and in the community, and we serve those communities.

The first thing about destination for all is we need to be embracing all people that provide healthcare, because they need to represent the communities that they serve. It is infinitely easier for somebody that understands the culture, the Latino culture of healthcare, to be able to meet somebody in that community, if it's heavily Latino, and understand where they're coming from, so that when they give advice it's culturally in context so that those patients feel, "They get me and I'm going to follow their advice because they get me."

But if I were to tell you that it was long held to my family's belief that by pass rolling sulfur rods over any area that of your body that hurt that you were pulling out evil humors, you tell someone that's trained in a Western medical school that, they immediately think, "What, are you crazy?" If you convey that sense of disbelief, you're just going to get the reaction you should expect, which is, "You don't understand me, so why should I follow you?"

I don't think we actually have enough diversity in healthcare from the provider base to truly represent the makeup of the communities that we serve. We need to do better at that. That begins by embracing people at a very early age so that they can get into medical education. The problem we have is employers in healthcare, even if you want to create a desk for all, is there aren't enough people coming out with cultural diversity to represent the communities that you serve. We have to fix that.

We're proud that we now are partnering with entities like Case Western Reserve, who has a Leadership Excel and Achieve program, where they take minorities that could not get into their CRNA school but who have potential, and we then take those candidates, give them a year immersion in bootcamp on how to bolster their academics, so that the next year, if they do well, they'll automatically go into CRNA school, so that we give people a chance by helping them develop the skills they need in order to successfully get in and stay in medical education. We need to get to do that more and more.

Embracing different cultures is one thing, and it's all about gender equality and paying people the same and treating people respectfully in your workplace. It is so much that we have taken for granted in this country in healthcare. I think we have to purposely attack this. We are doing it by we now have a DI officer who keeps us focused and has a lot of knowledge on how to move our company from where it is to an even better place.

We do a lot of education on the unconscious and conscious bias, regarding empathy and compassion and cultural sensitivity. I recently heard someone tell me that they understand that they have an unconscious bias and that unless they purposely work at it, they're going to come up short. It is something that they just have to understand that they have to go that extra mile. That's what we're doing, we're going that extra mile.

Tesha Nesbit, who's our DEI executive, began by saying, "What do you believe, John? Are you willing to sign the CEO pledge," which is an international pledge that CEOs of large companies will sign, committing to doing the work required as a proactive step to moving their company into a much better place. We've done that. It's a lot of excitement.

You talk about being destination of choice, even people who are not necessarily minorities or female or older population, whatever you call mainstream, everybody wants to know that you're embracing this. It makes it better for every everybody involved, not just subsets. We're very proud and happy to do it.

I see a day, hopefully, where we have an even distribution of healthcare providers that represents the communities they serve so that we can actually tap into those communities better than we currently do.

Camille Baxter: Thank you so much, Dr. Di Capua, for taking the time to really expand on this and help our listeners to better understand the challenges in healthcare with staffing shortages in anesthesiology, and what NAPA's doing to develop the leadership and voice of anesthesiologists to really help drive changes in the healthcare system.

Dr. John Di Capua: It's a real pleasure, Camille. It is so important that we talk about the issues that are affecting healthcare. It's only through the dialogue that we can find best practices. I hope that I've been able to share some of the things that we're proud of in our company and would love to see other people benefit from that. Thank you for hosting this.

Camille Baxter: Thank you, Dr. Di Capua. This has been a sponsored episode of Healthcare Insider, created in collaboration with NAPA. For more information about NAPA, please visit napaanesthesia.com.

I'm your host, Camille Baxter. Look for more episodes of Healthcare Insider at modernhealthcare.com/podcast or subscribe at Apple Podcasts or your preferred podcatcher. Thanks for listening.

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