Nicole Kerkenbush is a big proponent of shadowing. She regularly encourages IT folks to engage with caregivers, whether that means spending a few hours with a patient access clerk or going to the triage call center and observing how nurses use technology and, most important, the ‘pebble in the shoe’ problems that, if not removed, can cause dissatisfaction. Or worse, could prompt even more nurses to leave healthcare.
As a 24-year veteran of the U.S. Army Nurse Corps, Kerkenbush knows well how painful those pebbles can be, and believes technology can play a significant role in alleviating them. But it’s going to require collaboration among leaders, and a willingness to look at problems through a different lens. “Some of the solutions we’ve come up with aren’t going to cut it anymore,” she said during an interview with Kate Gamble, Managing Editor and Director of Social Media at healthsystemCIO. “We’ve got to dig into our creative side and figure out what’s going to work so that we can move forward.”
During the discussion, Kerkenbush spoke about her core objectives as Chief Nursing and Performance Officer at Monument Health, a 5-hospital system based in western South Dakota, most of which are centered around leveraging IT to improve patient care and processes while easing some of the burden on clinical staff. She also talked about the importance of building strong relationships – both within and outside of the organization; the most valuable lessons she learned during her time in the military; and the advice she would offer to aspiring leaders.
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- On project management: It’s critical to recognize that IT “is only a piece of the project. You have to look at the people, the technology, and the workflow.”
- On the workforce shortage: “It’s no longer about bringing in technology that we need more resources to run; we need to bring in technology that reduces the need for labor resources,” which Monument hopes to do through automation and robotics.
- On working with Dr. Patrick Woodard: “I think it really helps that we’ve previously had physicians who understand clinical processes and understand the fact that you can’t take all of the compassion and human touch out of healthcare and replace it solely with technology.
- On building relationships: “Go and talk with IT professionals or clinicians at [outside] organizations and see how they operate. That can open your aperture and let you see things differently.”
- On professional growth: “Think 5 years out. Think 10 years out. But be open to opportunity. It might not be the plan you had but if there’s an opportunity that presents itself, it could shift you in the right way.”
Q&A with Nicole Kerkenbush, Chief Nursing & Performance Officer, Monument Health
Gamble: Hi Nicole, thanks so much for taking the time to speak. I look forward to learning about what you’re doing at Monument Health. Can you give an overview of the organization?
Kerkenbush: Sure. Monument Health is a 5-hospital system. We have three critical access hospitals and two other hospitals on the western side of South Dakota. We’re in the Black Hills, which is the area where Mount Rushmore is located. It’s pretty spread out when you get outside of the main towns that are served by our system. We serve a fairly large geographical area, including the western half of South Dakota, and into Wyoming, Montana, Nebraska, North Dakota, and a little bit of Minnesota.
We do have an inpatient behavioral health hospital with around 50 beds. It has been pretty busy throughout the last few years and will probably continue to stay that way. At our main hospital, which is in Rapid City, we run an average census somewhere around 300 to 350 on a given day; that’s been up and down a lot over the last few years.
We have a cancer center, a heart and vascular institute, labor and delivery services, pediatric services, and advanced care pediatrics inpatient capability, as well as 40-plus clinics throughout the western side of South Dakota. We have some very small clinics; for example, in Buffalo, S.D., we do tele-dermatology and primary care from one clinic. We also have large family medicine clinics, surgical clinics, and an orthopedic hospital and sports performance institute. In total, we have about 5,000 caregivers and physicians.
We’re on the large side, but we serve some very small towns and some areas that are quite rural. It’s very important that those folks are able to get healthcare services.
The Chief Nursing & Performance Officer role
Gamble: In terms of your role as Chief Nursing and Performance Officer, this is something we see often. Can you talk about the role?
Kerkenbush: It has morphed a lot, even in recent years. I now oversee the nursing capacity for our entire system, which is all five hospitals and around 1,300 caregivers, including nurses, nursing support, and those in ambulatory and acute. We call all of our employees ‘caregivers.’
I also oversee the operational performance management group, which primarily has two focus areas. One is performance engineering. We have Lean-trained performance engineers who help us reexamine processes and workflows to get rid of waste. They’ve also installed a belt program that was created from the ground up. We have a white belt, a yellow belt, and a green belt program. We’re also working on a Gemba workshop program as well as a Six Sigma program. We’ve been very focused on that during the last few years to bring a consistent way of approaching problems. That includes clinical problems, administrative problems, finance challenges, employee challenges, and IT — it runs the gamut. Those performance engineers help throughout our system.
The project management piece
The other piece is our project management group. We have project managers in IT that are focused on IT components, but they can help with any project, even if there’s not an IT component. As your listeners know, IT is only a piece of a project; you have to look at the people, the technology, and the workflow. Those project managers help us keep everything running on schedule.
That operational performance management group also manages our planning cycles — operational planning and our strategic planning. They help us identify what are our needs, our goals, and the vision we have for the future. They’re a tool in our toolbox that’s very important in helping us stay consistent and bring an objective voice to the table as we’re working through all of the things we need to tackle in this post-COVID world.
When I first got here, I was in a role as the Vice President of Data Analytics. We recently hired a Chief Healthcare Information Officer, Dr. Patrick Woodard, who is taking the analytics component back into IT. That was something that I oversaw until recently. It’s the advent of the chief performance officer role; nursing had been added over time.
We remain flexible, as everyone has been during Covid. We’re continuing to figure out what’s right for our organization in order to meet the goals we’ve set for Monument Health to take care of the communities in the Black Hills.
Gamble: Right. It’s so important to be flexible and be able to adjust to different situations.
Kerkenbush: Yes. We have to adjust in ways that we haven’t before. Maybe some of the problems are the same ones we’ve dealt with for years, but we really have to start applying new solutions given some of the supply chain and labor challenges that have been an outcome of COVID. I think some of the previous solutions we’ve come up with aren’t going to cut it anymore. We’ve got to really dig into our creative side and figure out what’s going to work moving forward.
Monument’s core objectives
Gamble: True. At this point, what do you consider to be some of your most important objectives?
Kerkenbush: We have five priorities here at Monument Health. One is delivering high quality care — that’s really important, and it drives some of our main activities. We also want to deliver a great patient experience. We want to be a great place to work. We want to impact our communities, and we want to be here for generations to come. What does that mean for us at Monument Health?
Right now, our main hospital is on a journey to achieve Magnet designation, which recognizes quality nursing care and processes. We’re waiting to hear from the Magnet organization on how our process is going. We’re hopeful that we’ll have a site visit here in the near future and receive that designation. But that really makes us focus on quality care with our clinical outcomes as well as patient experience and caregiver experience. That hits three of our big priorities.
I’m also very focused on reducing workplace violence and supporting caregivers and physicians who experience it. It’s not new, but we’ve seen a lot more workplace violence in healthcare during the past few years. I think we’ve finally changed in healthcare our attitude toward that; no longer do we just expect people to deal with an angry patient or family member or a patient or family member that maybe is acting inappropriately because of a medical condition which could be some sort of brain disorder. It could also be that they’re under the influence of drugs or alcohol, or they’re receiving a treatment that they’re not tolerating well. We’ve taken a stance here that it’s unacceptable for patients, family members, caregivers and physicians to behave inappropriately with other caregivers and physicians. What we see most are family members and patients being inappropriate, and so we need our people to know that they’re supported and that they don’t need to tolerate that behavior. We’ve done a lot of work on that.
There are ways that technology can help. We need to be able to communicate through our EHRs if a patient or even a family member has acted violently against caregivers. And if it happens with an inpatient stay, we need to make sure that the caregivers in the clinic know so that they can be prepared. It doesn’t mean that we treat them differently; it means we can prepare ourselves better.
We’re also looking at ways to use technology to notify our security teams when there may be a problem in a clinic or in a patient room. Those are just a few examples.
Supporting the labor force
My third priority is the labor market, really focusing on recruitment and retention. It’s about working to top of license, top of education, and top of certification, and that’s in all areas. It’s nurses. It’s our accounting folks. It’s our EVS caregivers. It’s myself as the Chief Nursing and Performance Officer. If I’m spending time on activities that don’t require my training, education, and certification, then I need to figure out how to delegate those so that I can do the things that only the Chief Nursing and Performance Officer can do. This is another big area where we have no choice but to start asking, how do we use technology to support our labor force. I’ve been talking about this for a long time in the IT world, but it’s no longer about bringing in technology that we need more resources to run; we need to bring in technology that reduces the need for labor resources. We’re partnering with some of the vendor community on how to do that. There are some really great projects we’re working on in that space.
But I don’t see the labor force improving any time soon. We have to think about how we continue to take care of our communities but do it with fewer humans and fewer FTEs. And so, I’m looking at automation and robotics to capture information and get it into the EHR without forcing people to type or log in multiple times. All those kinds of things are part of my focus on labor.
And so, in a nutshell, it’s our Magnet designation, our emphasis on decreasing workplace violence and supporting our caregivers, and our recruitment and retention of the labor force.
Gamble: I would imagine that you have to walk a fine line where you want technology to support the labor workforce, but you don’t want to push technology on people. Can you talk about that?
Kerkenbush: The question is, do patients want a robot taking care of them? There’s been activity in that social robot realm. It hasn’t been super successful yet but I do think that there are ways to use technology but still maintain compassion and human touch. We’ve adopted technology in other parts of our lives and have perhaps resisted in healthcare. It’s time now to ask, how do we continue to do that? How do we maintain that high touch compassionate side but use automation?
Vital sign capture
We have a lot of tasks in healthcare that I think we could do more effectively if we employed the right technology. For example, vital signs. Right now, we spend a lot of time having our nurse aides, clinical assistants, medical assistants, and even nurses, LPNs and RNs, going into rooms capturing vital signs. Is there a way instead to do that through technology? Are companies working on ambient vital sign capture?
Trust in technology
I think that’s something we have to look at, because you don’t have to use humans to capture that. How can we build trust in our caregivers and our patients that technology can capture it safely, and then what can we do to repurpose the time that a caregiver was taking to put a blood pressure cuff on? Can they repurpose that to spend more time with the patient and listen to their concerns and do education or capture things that maybe they wouldn’t have had time to capture otherwise?
That’s just one example. We’re doing a few different projects with technology to figure out what we can capture. A lot of people wear an Apple watch, which captures your heart rate and tells you when to walk. It tells you when you’ve been sitting too long. I’ve seen commercials where the Apple watch can sense if you’re in a car accident and notify your emergency contact and perhaps call an ambulance. These types of things are already happening in our personal lives; let’s take that apply it in healthcare — in the hospitals and clinic.
How do we make sure patients don’t feel like you’re leaving them to the technology; that they still see the human side of this? How do we get our caregivers and our physicians to trust technology? That, I think, is going to be the trick.
Gamble: For all of these initiatives, I’m sure you’re working with other leaders throughout the organization. How is that structured at Monument?
Kerkenbush: We have a senior executive team that is incredibly supportive of each other and we’re very functional in how we work. I sit on that team along with our Chief Healthcare Information Officer, Dr. Patrick Woodard, who is new to our organization.
Previously, we had Dr. Stephanie Lahr as our CIO and CMIO. She and I worked very closely together. We had a high level of trust with each other. I expect to have that same kind of relationship with Dr. Woodard. I think it’s really important that we maintain that operational need and make sure that we’re explaining the operational need to our IT partners and have them provide solutions that we can then work together on. Nothing’s going to be perfect right out of the gate, but we have to work on those things together.
Clinicians in lead IT roles
I’m also very happy that our organization has continued to see the importance of a clinician in the lead role for IT. I think it really helps that we’ve previously had — and continue to have — physicians who understand clinical processes and understand the fact that you can’t take all of the compassion and human touch out of healthcare and replace it solely with technology. We will continue to work on that together.
Our CFO also sits on that team. It’s also incredibly helpful to have a great relationship with your CFO, because all this technology costs money. Technology, I think, has just continued to take up more and more of the operating budget of any healthcare organization, and so we have to be cognizant that we’re spending our money wisely and making sure that our finance partners see the benefit. I have a great working relationship as well with our CFO, Mark Thompson. We meet regularly to talk through my challenges and how we can solve those.
Trust and collaboration
When you have a senior team that has a lot of trust in each other and is willing to see that they may not agree on everything but that they can discuss opinions and potential solutions and come together ultimately on a decision that they can take forward as a group — even if it wasn’t what everyone brought into the conversation as their idea or solution — I think it’s really important. We can do that here.
We have an amazing CEO, Paulette Davidson. We often are in conversations with her as well about strategy — what does the future look like, and what is the vision that our board has set for us, and what do we want to do to achieve that vision? I think that’s super important, especially in these tough financial times. Because if you don’t trust each other and you can’t have open conversations, that would be a very difficult environment to work in. Luckily, I’m not in that environment. Our team really supports each other.
‘Pebble in the shoe’ problems
Gamble: That’s really important. But as you know, leaders come from all types of different backgrounds, even outside industries. Is there any advice you can offer for those who don’t have a clinical background on how to make sure they have the pulse of the caregivers?
Kerkenbush: Absolutely. I like to connect with healthcare technology caregivers who are young — either in their career or their age. Maybe they’re nurses looking to get more into the IT side or they’re IT professionals looking to get more into the healthcare side. I often tell these folks that it’s very important that they shadow, especially if it’s an IT person without much clinical experience. Shadowing is a great way to gain perspective. Follow a nurse aide for a shift. Go to the clinic and spend a few hours with the patient access clerk. Go to the triage nurse call center and observe the nurses taking calls. Watch how they use the technology, watch the challenges that they have, and look for the ‘pebble in the shoe’ problems. Those are things we get used to and just accept, but are annoyances. If the pebbles stay in the shoe long enough, you start to get really grumpy and you want to get out of your shoes or out of your workplace. We need to think about how can I see those things firsthand and how can I, as an IT professional, apply my skillset to help with those problems?
Shadowing is important, particularly for our helpdesk folks. They’re out in the operational spaces talking to other leaders and asking, what problems do you have? How are we doing? What can we do to make your job easier? Those are things that are really important.
I also think having them talk to people in other organizations and other areas of healthcare is valuable. We’re the only tertiary care organization in the western side of South Dakota, but there are primary care clinics. We have the VA and we have Indian Health Services (IHS). Let’s go and talk with IT professionals or clinicians at those organizations and see how they operate. That can open your aperture and let you see things differently. Helping people make those connections is something I do often to get them more experience and more perspective. That might be my main piece of advice for folks.
“Excitement” for the future
Gamble: That’s great. I would think it’s also beneficial for you to speak with people at different points of their careers. I’m sure it’s an interesting conversation.
Kerkenbush: It is. I speak with all of our new caregivers on the nursing and nursing support side who come to our organization. A few weeks ago, I spoke with our nursing support folks, which includes nurse aides, behavioral health techs, and emergency department technicians; afterwards, one of them came up to me. He’s a nursing aide who’s in our cybersecurity program. He wants to learn. He wants to do cybersecurity in healthcare — what better way to learn about some of those things than be a nurse aide? I really commend him for that. I said, ‘let me connect you with our CISO. Let’s get you talking with him.’ We want to capture him as a caregiver. We want to employ him.
When I talk to our nursing support folks, I get really excited about the future and I think, ‘we’re going to be all right, we’ve got good folks coming in.’ I think you really do have to talk to people and understand their desires; sometimes it’s going that far and taking a job as a clinical caregiver while you’re in school. I think he’s going to be very well positioned to do cybersecurity in healthcare in the future.
Learning leadership in the military
Gamble: For sure. So, the last thing I want to talk about is your previous experience. You were in the Army for a long time. Can you talk about how that helped shape you?
Kerkenbush: I spent 24 years in the Army Nurse Corps. The Army provided a wonderful opportunity for me. I received my Bachelor’s degree, two Master’s degrees, and a certificate. That’s how I received my formal training.
I also received amazing leadership training. As I’ve talked to other veterans too who have come out of the military and gone on the commercial side or the civilian side, we’ve found that it’s not the same out here as it is in the military when it comes to leadership training.
That’s something that, in retrospect, I really value from my time in the military. If you stay in, you will routinely go to leadership courses, and you’re expected to be a leader. I think that’s really what has helped make me successful as I transitioned into the civilian world.
As we’re coming out of Covid, we’re revamping our leadership program here at Monument Health. I think we need to really emphasize that, and I’m not alone in that opinion. We have good support for that. But I think some of what we’ve gone through in the last few years has shown us that it’s not the clinical experience, but the resilience you build by being in a leadership role and going through failure and success — that really makes the difference.
Honestly, the problems and the challenges I faced in the military are not any different than what we face in the civilian world when it comes to healthcare. The payment model is extremely different, but I think my experience has helped because I had a different version of payment for healthcare in the military. I’ve learned, and I continued to learn daily, about the payment model out here, but I think we can learn a lot from each other.
I have colleagues who are CIOs and CNOs in other parts of the country and we lean on each other. I call them up and say, ‘I’m dealing with this — what are you doing? I’ve learned so much from them. Hopefully, I can repay the favor at times. The networking aspect is invaluable. The group of people that you build in a 24-year Army career can really help you even when you leave. So, it’s a few things: the leadership training. I think that’s a couple of things — it’s the leadership training and the foundation of the network that I built that really helped me.
Healthcare is a small world. The military is a small world. When you put them together, it’s an even smaller world. I still often interact with folks that I worked with over the last 24 years; some are still on the federal side, and we talk about that. Others are now in commercial healthcare systems like I am, and we talk about that. But it remains a very tight knit community.
“Be open to opportunity”
Gamble: It seems like that was really a great foundation.
Kerkenbush: Definitely. It was not my plan. I have a high school senior this year; he’s getting ready to go to college, but I tell him, be open to opportunity. You need a plan. You should be thinking 5 or 10 years out. I think the Army really taught me that too. They make you think that way, because they want to have a path charted so they know where everybody is going. Think 5 years out. Think 10 years out. But be open to opportunity. It might not be the plan you had but if there’s an opportunity that presents itself, it could shift you in the right way. And finally, it’s all about relationships. Those are my three mantras: have a plan, be flexible, and it’s all about relationships. Build those relationships; don’t ever burn a bridge. You never know when someone might be there to help you. Those relationships can be so important as you try to get to the next step in your career, even retirement. I’ve retired once and I plan to retire again, but then I hope I can lean on folks to go visit them in various parts of the world. But yes, relationships are important.
Gamble: That’s fascinating. I’m always interested in hearing about people’s experiences, especially in the military. Well, I want to thank you for your time. This has been great.
Kerkenbush: Absolutely, anytime.