Joe Fuller: The vital signs of the U.S. healthcare workforce aren’t promising. There are shortages throughout—from doctors, nurses, and clinical assistants to pharmacists and home health aides. Covid-19 drove up the burnout rate, and retirements have added to the labor crunch. With no reduction in demand in sight, what can the industry do to increase the supply of workers? And what are the keys to keeping workers on the job, sustaining careers, and reducing costly turnover?

Welcome to the Managing the Future of Work podcast from Harvard Business School. I’m your host, Harvard Business School professor and nonresident senior fellow at the American Enterprise Institute, Joe Fuller. I’m joined today by Kelly Hancock, Chief Caregiver Officer at Cleveland Clinic. We’ll discuss the state of the healthcare workforce, the pressure points of shortages, and new sources of talent. We’ll talk about the academic medical system’s workforce strategy and community engagement and how the two build on one another. Then we’ll consider the role of skills-based hiring. And we’ll look at how artificial intelligence is changing both healthcare jobs and healthcare HR functions. Kelly, welcome to our podcast.

Kelly Hancock: Thank you, Joe. I’m happy to be here.

Fuller: Kelly, you’re the Chief Caregiver Officer of the Cleveland Clinic. Many of our listeners will know Cleveland Clinic. It’s one of the most famous healthcare delivery organizations, really, in the world, but not many people, I think, will know what a Chief Caregiver Officer is. Could you tell us about your role?

Hancock: Sure, thank you. So our employees here at the Cleveland Clinic are referred to as “caregivers,” so whether they’re clinical or non-clinical employees. So we have 81,000 caregivers across our global footprint, and I have the privilege to serve all of them in this role as the Chief Caregiver Officer. So this is like your Chief Human Resource Officer with other centers of excellence to really support the vision of the organization, and that vision is to be the best place to receive care and the best place to work in healthcare.

Fuller: Developments in the healthcare sector in employment are very widely written about—throughout Covid, obviously, where so many essential workers from healthcare were put through immense burdens, very stressful, lots of early retirements, lots of changing in the market for nurses with more agency-provided nurses and employed nurses. I know you have a background in nursing. What are the most important things that our listeners need to know about what’s going on in the market for talent and skilled work in healthcare delivery?

Hancock: When we think about our workforce and the talent shortage, it’s really critical here in healthcare. There’s been this national shortage of registered nurses, and the pandemic just really exacerbated that shortage for a variety of different reasons. So the challenges related to nursing and other mission-critical roles continue to plague us, although it has gotten better. It’s gotten better because of investments that have been made in recruitment and talent acquisition teams and “sourcers” looking for that talent, as well as the strategic investments in retention efforts in the organization. They have been a key focus.

Fuller: Shortage in capacity to create people with the skills and credentials? Is there a lack of people going into the field? What about beyond nursing, when we talk about various med techs [medical technicians] and everyone from people who do imaging to the surround that support doctors and nurses in providing care?

Hancock: Yeah, specific to nursing, it’s really a pipeline issue. So many of our academic partners are also challenged with shortages in terms of faculty. So many healthcare organizations are partnering to see how they can mitigate that with utilizing their own talent within their organization to serve as faculty, both in the classroom setting as well as in the clinical realm. So that is one way that we’re trying to mitigate those shortages, so we can bring more students into those programs. As it relates to other mission-critical roles in healthcare, we have shortages in medical assistants, those assistants in imaging and technology. So, like other healthcare organizations, we really have shifted to looking more to hiring for skills and competencies as opposed to education, where education is really not required. So looking to see, again, how can you build those pipelines to bring the talent into the organization?

Fuller: You mentioned, in describing the Chief Caregiver Officer role, one of your objectives of being the best place to work in healthcare. What, beyond the core elements of job offers like compensation and benefits, are you looking to meet that very, very ambitious standard?

Hancock: That includes physical well-being, mental health, fiscal well-being—really making that a top priority. So we have issues and programs to address burnout, increase resiliency. We have appropriate support for mental health to really enhance the overall well-being of our caregiver. So utilizing these resources to take a holistic approach to ensuring that they feel that they’re being supported.

Fuller: Now, Cleveland Clinic has multiple international sites, too: Abu Dhabi, London, Canada. How does that vision play out when you go to other markets, other labor markets, but also other regulatory and other regimes?

Hancock: Absolutely. So in our domestic footprint in our facilities in Ohio and Florida, the approach is very similar. Yet, there’s some uniquenesses to those markets. But the overall initiatives and programs that support the well-being of the caregiver remain consistent. So we do have that uniformity, as well as in our international locations. It’s really important—particularly for the mobility of our caregivers—that, no matter where they go in our healthcare organization, they can and should expect the same type of support. I think a good example of that is, when we asked some of our caregivers during the pandemic to volunteer to go over and help our teams in Abu Dhabi who were facing the surge of patients, they went over for seven weeks. When they came back, we sat down to speak with them to see: “What was it like? Did you feel like you were at a Cleveland Clinic facility?” They said, absolutely they did, and it’s for all those things that I mentioned.

Fuller: Let’s come back to zero in on the United States now, because you touched on something that’s near and dear to our heart and the Managing the Future of Work Project here at Harvard Business School: this notion of developing additional pathways for people to get into good-paying jobs that go beyond traditional degree-granting institutions and can be the basis for both creating a talent pipeline that fills needs that the market is not otherwise filling, but also contributes to objectives like increasing the diversity of the workforce. Can you give us some illustrations of what you’re doing specifically to accomplish that?

Hancock: Sure. So one thing is that Cleveland Clinic, it was one of the founding organizations of the OneTen Coalition. OneTen is a coalition that brings like-minded organizations together with the idea of bringing in 1 million Black Americans into family-sustaining roles over the next 10 years. It really allowed us to take a step back and look at those roles within our organization in terms of their requirements, where traditionally, perhaps, they would require different certification or different education. When we examined that, really to understand: Is there a value-add, or do we really remove that barrier, if you will, and focus on the skills-based approach, competency-based, into bringing talent into those roles in the organization? We took that approach by ensuring that we develop some apprenticeship programs to support our colleagues coming into those roles, because the idea of “earning while you’re learning” on the job, getting that experience, is so important, and we’ve been very successful in that approach. Bringing in local talent from our communities in which we have a footprint is a focus for us in terms of local hiring. And it’s a win-win. From a patient perspective, they have caregivers who are caring for them that look like them, that can appreciate understandings of different environments, and it’s really been helpful for us.

Fuller: Were these the first apprenticeships that you had set up, or did the clinic have experience with apprenticeship programs prior to this thrust of yours?

Hancock: Sure. So the clinic has had some experience with different internships and apprenticeships over the years, of course, but this specific apprenticeships with OneTen was unique in some of the nontraditional areas that we’ve not had them in—such as pharmacy, which, by the way, is our longest-running apprenticeship program since we began this work with OneTen. We have an apprenticeship in the epilepsy area of the hospital and the sleep lab. Even have had great success in developing an apprenticeship in ophthalmology. We had 90 apprenticeships that were trained just in 2023 alone, and that really brought us over our goal of just having 40 apprentices. Our retention rate was 76 percent last year, which is notable.

Fuller: Certainly, in a market where there’s such a consistent propensity for competitors to steal talent—especially talent coming from an organization with a reputation of the Cleveland Clinic—a lot of companies have expressed interest in apprenticeship. It’s a word that’s bandied about pretty loosely by people. If I were coming to visit you and say, “I’m thinking about setting up an apprenticeship program”—maybe not in healthcare, maybe I’m a manufacturer or financial institution, what are the three or four things you would tell me that have allowed you to have that retention rate, that have caused you to grow the program beyond your targets? What are the practical policy and practice steps you have to take to make it work?

Hancock: I think, first, understanding what wraparound services and training you need. There were some foundational skills that were needed for those going through those programs—such as punctuality, transportation, supporting them with appropriate communication for when they need time off, professionalism, those type of things, childcare resources. Once we were able to identify those skills that were needed and develop that training program, we made sure that all of those apprentices went through it, as well as the leaders. That would be my second tenant for success, is really engaging those leaders, those subject-matter experts, over those areas to get their buy-in so they can also see the value-add.

Fuller: Kelly, I’m interested in how you’ve aligned resources beyond those of the clinic to accomplish this. So often we find that big institutions find it extremely difficult to find educators, social services, to get local or state governments to provide services that provide this wraparound that you’re describing. How have you built an ecosystem around this?

Hancock: Sure. So as an example, in Ohio and in Florida, we collaborate with over 75 different local colleges and community colleges, et cetera, to help us meet the need. We also take advantage of those resources within our communities, those community network resources, to help us provide those wraparound services. So again, whether it’s leveraging a need for childcare, transportation …

Fuller: Well, we’ve certainly observed in our research that aligning those resources—particularly with community organizations and educators who really know the local populations and know what they need and are familiar with it—is really an essential part of making these programs work. Because the extent to which problems that don’t bedevil incumbent workers like unreliable transportation, like erratic childcare availability, HR isn’t configured to handle that in most big companies. And so you need to find another mechanism to do it. Let’s turn to your incumbent workers. We’re talking in January 2024. We’re seeing a level of technological change that is continuing to accelerate. I’m curious about how—particularly for your nonclinical staff, all the surround-services technicians, whatnot—how you’re addressing the issue of reskilling, how you are keeping your workforce up to date.

Hancock: Absolutely. So skills-first hiring and job recredentialing is important for us, and it’s about redefining those jobs based on skills and experience. We now have over 400 jobs within our organization that are skills based, and examples include a program manager—so these are the nonclinical ones that you refer to—a department supervisor, a department analyst. A great example is we had a caregiver who was here 20-plus years, and an opening came up as a supervisor role, but they just did not have that four-year degree. It was a barrier and a limitation for mobility within our organization. So we were able to remove that and look at the skills, recredential that role, and utilize that experience in that department so this person rose to that level. I think that’s what organizations need to continue to do. It’s also interesting, though, I’ll share with you, we had a community hiring event. We had one of our leaders ask a group of our community members to raise their hand if they identified with some of the skills that she was mentioning, which was needed for one of our skills-based roles in the organization. It was interesting to see a variety of the hands go up and people say, “Well, you know what? I can relate to that kind of role. I can do that type of a role.” It’s encouraging for those who work in our organization, as well.

Fuller: Well, certainly, the thought that there are opportunities to continue to grow in a company and that the company—in this case, of course, a healthcare provider like Cleveland Clinic—is actively finding ways for people who’ve been effective performers, really shown their commitment to the organization—in your case, to being a caregiver that they can advance, progress. Also in our research, it correlates to lower voluntary turnover, higher levels of engagement and productivity. It’s really a virtuous cycle.

Hancock: It certainly is, and we’ve heard over time from our caregivers that they did want these career pathways. Our team has developed seven career pathways to help accelerate that career advancement that you were mentioning and that promotion of our caregivers from those entry-level positions up through those other redefined roles. These career paths have over 50 next-level jobs that one of our caregivers can pursue, providing an option to fit their unique skills and their aspirations. So one of the career pathways that we have here in the organization is having one of our entry-level nursing assistant jobs, called a “patient care nursing assistant” or a PCNA. They can come into the organization in that capacity, and if they have a desire to go back and really want to become a nurse in our organization, their next step is becoming an LPN—or a licensed practical nurse. Again, we’re going to support them through our tuition reimbursement while they’re working here. When they’re done with the LPN, and they want to pursue the registered nursing, again, we have so many academic partnerships, they can go take advantage of our tuition reimbursement and become a registered nurse, and then be employed within our organization. So that’s a wonderful example of a career pathway beginning with an entry-level position that really supports our current incumbents.

Fuller: The healthcare sector has a reputation, certainly among the academic circles I travel in, of having a demand for a lot of different types of entry-level roles, but having barriers in terms of credentialing to advancement. Is that a fair characterization? If it is, are those barriers really a function of institutional policy, or are they legal requirements, licensing requirements, things like that?

Hancock: I would say that part of our discovery—by going through this process about reskilling, removing those barriers—what we discovered is some was legacy in nature, in terms of the education that was required. Now, of course, being an academic medical institution, we value education, and we support that. But when we looked at those specific roles, really understanding, did that education provide value? Or, rather, is it that experience, that competencies, that are needed? Now, of course, there are always going to be degrees that are regulatory required—those for a registered nurse, obviously our physician colleagues, and other roles. But what we’re seeing is, there’s less that were required for some of those nontraditional roles that you would imagine needed an education, and this just really allows for us to continue to focus on the growth and development of our caregivers, which of course, they appreciate.

Fuller: Well, as I mentioned earlier, here we are in the chilly January of 2024, and you basically cannot pick up a newspaper and not find at least one article that starts talking about artificial intelligence, its role in work, how it’s going to make some people more productive, other people lose their jobs. How are you approaching AI at the clinic, both through the lens of skills development and upskilling the people you do have?

Hancock: In terms of utilizing AI from a caregiver office standpoint, we’ve leveraged AI to really streamline the recruitment process by automating resume screening and identifying potential candidates for particular roles. What it has allowed us to do is really streamline our candidate journey—from application to offer—within a 12-day timeframe, which is much more abbreviated than our experience in the past. Our approach, then, allows candidates to self-schedule interviews with the recruiters and those hiring managers. It reduces the time to fill, as well as it sends automated follow-up emails and text messages, so people understand where they are in the process. Leveraging AI, in terms of onboarding our caregivers, has also been beneficial for us as well. So we continue to explore chatbots that can assist in the onboarding process, because, as you can imagine, we have a lot of information to provide. So they allow us to provide that information, while at the same time answering important questions that our caregivers may have, and really guiding them and their hiring managers throughout the entire process.

Fuller: Using AI to qualify and evaluate candidates—less sophisticated AI than generative AI—has been used for that purpose for a while, but it’s often been counter-correlated with skills-based hiring, because it’s easy for the AI to spot credentials and letters like “BA” or “BSRN” or whatever else, but it’s much less adept at inferring skills based on work histories. How are you balancing those two considerations?

Hancock: Sure. So AI tools that we utilize today, they do help us assess and identify skills of caregivers that allows us to understand the current skill set within our organization and how there’s a fit. And we also have used this to identify training programs based on individual caregiver needs. The last thing I would add on that is, automation and AI really has the potential to lead to the redesign of certain jobs and certain roles in an organization, and we found value in that. Repetitive and routine tasks that many of our caregivers do—they need to do—may be automated, and that allows caregivers to really focus more on core elements of their role and allows them to be a bit more creative and obviously leads to that satisfaction.

Fuller: Research indicates that, really, AI’s penetration is going to be to take tasks out of jobs more than displace jobs and allow people particularly to be relieved from very routine tasks, with lots of consistent elements that are strictly necessary but really don’t engage people’s creativity and energies in ways that you would like. It also is a great leveler. Some of my colleagues at Harvard Business School did some wonderful research that showed that, among consultants in a major consulting firm, the performance of individuals who had been ranked in the bottom quartiles, two quartiles, improved to converge with that of their colleagues in the top two quartiles when they were supported by AI. Other research shows that new workers get productive faster when supported by AI tools. So I think there’s an awful lot to be excited about, in terms of what this can do, in terms of unlocking people’s both productivity and enthusiasm for their work.

Hancock: I would agree with you, and we have some great examples of that in our organization. We mentioned earlier in our conversation the medical assistant. That is a critical role in the organization that’s hard to fill, and it was before the pandemic. So we really leveraged AI with really looking at the repetitive and routine tasks that a medical assistant does every day and see really what can be automated to allow them to have more fulfillment and allow them to really be with the patient and focus on some of the core elements. As you pointed out, things like empathy, problem solving, and creativity are uniquely human tasks. So, if a task doesn’t require one of those three things, it can be done by a machine. So we’ve really found some value in making sure that people are practicing to the top of their relationship and are feeling fulfilled. Leveraging the virtual platforms to extend our clinical reach to serve more patients in need of Cleveland Clinic care is a top priority for us.

Fuller: Kelly, one thing that certainly in my conversations with leaders in large organizations as they’re finding out about AI is that AI is a little bit unnerving to incumbent workers. People are questioning, how is this going to affect their jobs? Will it jeopardize their long-term prospects? How are you approaching this, in terms of a labor-relations issue? And how do you engage a big, diverse workforce—where you’re going from everyone from research physicians right down to new people, for example, in that PCNA role you mentioned? How are you managing AI and labor issues more generally?

Hancock: A relatively small portion of our workforce is represented in terms of unions. We devote a substantial amount of our time to those working relationships to ultimately establish and really maintain common priorities for the benefit of patients and the benefit of all caregivers. So, with that philosophy in mind, we can collectively focus on excellent patient care and outcomes, and all those conversations, and how do you leverage AI so they can understand we’re not replacing individuals, but really excelling in high-quality care, really focusing in on the health of the communities we serve, and ensuring the safety and welfare of all caregivers. This approach enables decisions—such as training, the skills, the educational opportunities, the advancement, mentorship—really to be made from the standpoint of a shared patient-focus priorities and also to support the caregivers. So that’s really been our approach.

Fuller: A lot of organizations have also grown more and more dependent on what we think of as “on-demand talent providers.” They rely on big, very sophisticated companies—like the Randstads of the world—to meet surges in demand for work or just simply to offload the burden of continuing to replace staff that attrits, that retires, that are subject to involuntary turnover, termination. With a company that’s got such a strong culture and this caregiver commitment, how do you view those resources? Are those things you use?

Hancock: Our experience with on-demand hiring has really been focused in those high-demand areas, so those that we mentioned already: nursing, some patient-support roles. Like many healthcare organizations since the beginning of early 2022, we had to rely heavily on agency workers. However, we have significantly reduced that need—this past year, in particular—because we’ve been able to leverage that on-demand hiring for registered nurses, bring them into the organization. We have experienced better-than-ever retention rates, which we’re very proud of, because of the investments we’ve made in the organization in and into our people. And, therefore, we’ve had to utilize that tactic less.

Fuller: Kelly, you’ve written about the concept of shared governance. How do you define that? And how does it manifest itself at the clinic?

Hancock: Well, we know that shared governance can really be transformational, particularly in healthcare. In terms of shared governance, from an HR standpoint, I think the important piece, there’s as a couple key tenets, one of which is listening. We do so through a variety of different mechanisms, such as our annual engagement survey, where we ask our caregivers to tell us how we’re doing. A benefits preference survey. Last year, we administered a benefit preference survey to all of our caregivers, because we wanted to understand, with 81,000 caregivers in the organization, we know it’s not a one-size-fits-all, and what matters most to them, where they’re at professionally and personally. We’ve done some persona studies, as well, just really having a better understanding of what our caregivers need, not only now, but in the future. Collaborative decision making. So part of shared governance is really engaging those “teams of teams” and developing specific objectives and key results, or OKRs, for every leader around collaborative decision making. So that gives an opportunity to review those results with those that they serve, those leaders, and they can then decide as a team what to focus on as they move forward. I would also add that communication and transparency as a key element of shared governance, and HR departments need to really communicate openly about decisions in an organization—about the policies changes, et cetera—because it goes such a long way. Inclusion, another key tenet of shared governance. This may involve the establishment of committees, councils, or different forms, where all caregivers can be represented, such as employee resource groups or diversity councils. So I think, when caregivers feel that their input is valued, it can enhance their sense of ownership, commitment, and belonging to the organization.

Fuller: You mentioned diversity. Students for Fair Admissions v. Harvard and University of North Carolina—the consequences of that are beginning to be felt in terms of corporate diversity efforts. Any thoughts about challenges that are going to emerge because of the turbulence caused by that decision?

Hancock: Well, we still hold true to our commitment of diversity, equity, and inclusion in the organization. As you pointed out, the recent SCOTUS ruling really sparked many conversations across the country and questions on what people should or should not be doing. For us, the answer is: we still stay true to our commitment. Our DEI efforts are incorporated, really, into our business strategy and woven into the four care priorities of the organization, which is caring for our caregivers, our patients, our communities, and our overall organization. So we’ll continue to hire and develop our caregivers, whose diversity reflects the communities in which we serve. We continue to focus on our students in our pipeline programs, particularly for underrepresented minority students, to increase representation in healthcare professions. We continue to offer different seminars, training, and other career-development programs to enable our caregivers to deliver more equitable care across our global footprint.

Fuller: Kelly, there’s been a lot of change at Cleveland Clinic over the last few years because of technology, because obviously Covid, and whatnot. Hopefully, we’ll have more peaceful and tranquil time in the next few years. But what do you think we can expect to see from Cleveland Clinic, both in terms of it as being a place for great caregivers to work, but also more broadly?

Hancock: Well, I would say the workforce shortage is not going to go away anytime soon, and we understand that. So I think, as an organization, how we adapt and continue to care for our patients and our caregivers, as well as the overall organization, under these constraints will continue to be a focus for us. We’ll continue to think about role redesign, creating new jobs, deploying tasks to other jobs, or leveraging technology. Really focus on how do we continue to build that talent pipeline specific for those hard-to-fill jobs, such as nursing and other support roles. Continuing to look at AI, utilizing it across the enterprise to enhance both the caregiver and the patient experience. Those are really some of the top priorities for us in the next couple of years.

Fuller: Well, Kelly Hancock, Chief Caregiver Officer at the Cleveland Clinic, such a pleasure to hear about all the many things you are doing there to be innovative and creating an environment for the top caregivers in the world and looking forward to seeing what unfolds in the next few years.

Hancock: Well, thank you, Joe. It was a pleasure to be here today.

Fuller: We hope you enjoy the Managing the Future of Work podcast. If you haven’t already, please subscribe and rate the show wherever you get your podcasts. You can find out more about the Managing the Future of Work Project at our website hbs.edu/managingthefutureofwork. While you’re there, sign up for our newsletter.