As the largest provider of behavioral health services in New York City, NYC Health + Hospitals delivers nearly 60% of all mental health and substance use services citywide. Omar Fattal, MD, system chief of behavioral health, told Becker’s Behavioral Health podcast how the system restructured its workforce strategy, centralized efforts across a complex system, and made difficult investment decisions to improve access and retention.
Editor’s note: Responses have been lightly edited for length and clarity.
Question: NYC Health and Hospitals has reduced behavioral health turnover to 8% while the national average is over 30%. From an enterprise perspective, what fundamentally changed in how the system approached the workforce?
Dr. Omar Fattal: The biggest thing that we did is really focus on the workforce as its own strategic priority. I’m a big believer in the saying that what you nurture grows. We applied that same concept to the workforce in the sense that, in the past, I’ve seen and heard a lot of people talk about the workforce but then not necessarily do something about it, or be passive or expect other people to work on it.
What we did a couple of years ago is put out our strategic plan for behavioral health for NYC Health + Hospitals. That includes what we call the behavioral blueprint. It includes six strategic priorities. Most of our strategic priorities are related to access, because access is the ultimate goal, and that’s the one thing that we really needed coming out of COVID. There was a mental health crisis. We have the opioid crisis. We have a crisis for adolescent and children’s mental health. So we people needed access to services, and that was our goal for inpatient, outpatient and special populations.
We insisted on having the workforce be a strategic priority in and of itself and be able to focus on it. We think that that, honestly, was the basis of what led to these results that you mentioned earlier, and our strategic plan within that strategic priority. So not only did we name it as a strategic priority, but we came up with a comprehensive strategic plan to be able to deliver on that strategic priority.
That strategic plan has three pillars, and that’s another key difference. In the past, we might have seen a focus only on recruitment or a focus on only training in a bit of a disjointed way. The nice thing about having a strategic plan and thinking about this work in a comprehensive way is to be able to focus on these three pillars in parallel. Because in our experience, and I think other people’s experience, if you’re only focusing on recruitment and bringing in new people, but then you’re losing people on the other hand, then obviously you are not getting a net increase in your workforce. We wanted to tackle those two issues simultaneously so we can make sure that the people we are recruiting, we’re keeping them, and they’re growing in our system.
Q: What are some of the initiatives under those recruitment, training and retention pillars?
OF: Those three pillars, as I mentioned, are recruitment, training and retention. For recruitment, we’ve been very focused on campaigns. We have been able to distill our main selling point for working at NYC Health + Hospitals, and that is our mission I mentioned earlier, caring for all New Yorkers, without exception. And that’s a very big mission. And in our case, it’s truly what we do. Sometimes statements or missions that are stated don’t necessarily translate into everyday impact or everyday reality. In our case at NYC Health + Hospitals, everyone will see for themselves the minute they start working. Here we truly live that mission every single day, and us being able to capture that through the voices of people who work here and people in leadership roles has resonated with a lot of people who really are attracted to this kind of mission.
We’ve also been getting creative in the ways we’ve been recruiting. We have not spared any means. We started with digital, then we expanded to social media and to out of home, which we experimented with. And finally, we added cable. We have not left any stone unturned in terms of using every modality that we have to be able to get the word out there.
We did not only rely on people joining from the outside, we focused on our own pipelines. So one example of that is our peer academy. Our peer academy is a program that we administer ourselves, and it takes people with lived experience, whether it’s mental health or substance use, who want to be peer specialists, and we put them through it. We expose them to real life internships in our facilities and we prepare them. We coach them on how to interview and how to apply for a job. We’ve been able to graduate more than 100 peers through this program, and most of those peers took jobs in our system.
Moving on to training, our second pillar. Training is both for retention, but also for recruitment. One example under training is our psychiatric physician assistance program. We’ve had a chicken-or-egg situation with psychiatric physician’s assistants. Historically, we did not have a lot, or I would say we didn’t have any psychiatric PAs in our system. We only had one facility that had used them. So we, our chiefs, were reluctant to hire psychiatric PAs because they don’t have them and they don’t have psychiatric PAs to supervise the new PAs that you’re going to hire. But then, if you don’t have them, then how are you going to get them? So it was a little bit of a chicken or an egg situation.
This program we started was meant to break that chicken and egg by providing a comprehensive three-year program that meets physician assistants, even as students, to expose them to behavioral health, then give them training and end with one-year fellowship, which we started last year, where they spent a whole year doing behavioral health work and getting wrap around supervision mentorship to prepare them to be able to become the next generation of PAs who will then, in the future, supervise and mentor the new PAs that we will be hiring.
Lastly, under retention, our BH4NYC loan repayment program has been really the cornerstone of our retention efforts, and this has been really an amazing and very popular program. It was made possible through very generous donations from philanthropy. It started with a $1 million donation, and then we got a larger donation from the Black Family Foundation that really helped carry that program to where it is now. And that program, the gist of it is to be able to give loan repayment grants in return for the three-year service commitment. And that has been really very helpful for us.
Q: At your scale, workforce efforts can fail because they’re fragmented. What did you have to standardize or centralize to make this work across the system?
OF: Yes, this is definitely something that we observed early on. We are a very large system, in the sense that we have 11 acute care facilities and more than 30 community health centers. And fragmentation can happen at the level of departmental fragmentation, in the sense that you have HR, finance and program leadership really not being on the same page, and a lot of things fall between those cracks. The second fragmentation is fragmentation within the system — let’s say between those 11 facilities, or between the system leadership and the facilities. And we’ve really worked on both fronts.
For HR and finance, what we did early on, and that was one of the reasons why having strategic plan was very helpful, because we were able to bring everyone around the same table and look at the same plan, look at the same goals and same objectives and kind of have consensus around where we’re going with all of this. So we did a lot of prep work with our finance colleagues, who have been very amazing and supportive, and our HR colleagues have been very supportive as well. But it helped having a shared vision and having shared understanding at the level of the numbers and the vacancies so that they knew what was happening.
We did a lot of preemptive work, in the sense of preparing everyone on what to expect and what’s coming so they’re not surprised when they see them. They really appreciated that a lot. The second work that we did was more at the level of the system in general. And to your point, a lot of things can go bad when you’re fragmented, because you can have duplication of efforts or confusion or waste of resources. What we’ve done is really centralized the scaffolding, support and structure, but not the people, in the sense that we definitely standardized data. You cannot do this work without data. You cannot fly this plane completely blind. And you really need to know how many vacancies you have. For every program that we have, you have to keep track of, “Is it working? Is it not working?”
We worked on creating a whole data infrastructure that captured our programs, our vacancies, our positions and that has been very helpful and continues to be very helpful to keep an eye on retention. What we also did is standardize the processes and workflows. We do a lot of work with other external partners, including having students in any discipline spend time with us for internships, for all kinds of experiences, and we’ve standardized all of that in the sense that we have the same contract that we use everywhere. But also we have centralized the intake process. If you’re an NP student or your social work student looking for placement, instead of you having to contact 11 different facilities, now we have a centralized way of applying and having your application process and interviews and all that stuff is streamlined. And lastly, which I think is the most important part, is having a dedicated team that is focused on this work. If you have a strategic priority and you have a strategic plan, you need dedicated people who are focused on making sure that they deliver on the results of this plan that you put together.
Q: What were the hardest leadership decisions you had to make to get these results?
OF: The biggest and hardest decision was deciding whether we “shelter in place” or expand. Starting this work a couple of years ago, we were coming out of COVID. With COVID, it still left a big impact on all of us. We were decimated by COVID in the sense that we’ve lost more than 200 psychiatric beds that were turned into medicine beds from a workforce. So serviceswise, we’ve lost a lot of momentum and workforce.
The big decision was, do we try to just fill in the small gap that we had and just try to get back to where we were, or do we expand? Because at the same time, we were faced by not only needing to go back to the level of service that we had before, but there was a big mental health crisis that we were facing as a city. There was an increase in demand for services, and simultaneously, we were trying to get back to where we were. The reality is, there were a lot of financial opportunities that presented itself at the same time. So the question was, do we take advantage of these opportunities and expand while knowing that we were down, and that was a big risk, versus just saying no to expansion and delaying things.
We decided to go all-in for two reasons. One is because we really felt the sense of obligation and the sense of responsibility to the city to meet that need. We felt that it was not really a choice for us to not be able to respond and grow and meet the need. And the second reason is more practical. I’ve seen this a lot in the past, and I’ve seen it myself working in some environments, is sometimes in an environment of scarcity, what happens with especially workforce is, if you don’t have enough, then what people end up doing when they’re cutting or they’re not being very focused on growth, what ends up happening is that the people that you have end up burning out, and then they end up leaving. Then you end up losing more people and in this vicious kind of negative cycle where it ends up being a very unhelpful situation.
But what we did is instead expand, and ironically, when you expand and add more people, you end up retaining more people, because those you have are feeling better, and they’re happier with their job and are more satisfied. Then they go tell other people that this is a good place to work, and that creates more of a positive spin on the whole situation. It was a risk that we took, but I feel like now looking at the results, I think it paid off.
