Step 1: Multidisciplinary Teams to Address Steps of Recruitment

The initial group responsible for hiring included CMO, ACMO, human resource personnel, occupational health services, and credentialing personnel. This group developed into 5 subteams based on the steps of recruitment and expertise of each team member. These teams were developed by consensus among the leadership group. The expertise of these teams allowed them to anticipate the potential challenges with hiring and apply the best practices of the traditional hiring process.

1. 1. Communication team: responsible for outreach, communication with applicants, setting up the interviews, and screening of applicants.

2. 2. Interview team: responsible for identifying appropriate candidates during interviews and matching the candidate to a potential role in the hospital.

3. 3. Credentialing team: responsible for expediently ensuring clinician’s compliance with practice standards set by the State of Maryland and credentialing institution that is, JHM.

4. 4. Occupational health team: responsible for ambulatory health screening of staff and training for infection control practices.

5. 5. Onboarding and scheduling team: responsible for providing brief—yet, inclusive—onboarding, including scheduling the providers’ clinical shifts in the hospital.

Step 2: Needs Assessment

Field hospitals can provide a spectrum of care, based on their intended purpose, from critical care services to convalescent care. ^{Reference Yuan, Sherryn, Hu and Chen1} This purpose is determined by the characteristics of the at-risk population and regional resources. The level of medical care at the type of field hospital, term of operation, the admission criteria, and the level of resources required would inform the required expertise and the number of required staff. ⁷

1. 1. Whom to hire: The CMO and associate CMO made this decision with inputs from the nursing leadership. This was informed by the admission criteria of the field hospital and as well as the regional availability of the required clinician expertise. During the initial setup, the BCCFH provided low acuity convalescent care to patients with COVID-19. There was an increase in the furlough of the outpatient providers, subspecialists, and urgent care providers during the initial surge of the pandemic. ^{Reference Gooch8} This provided a trained pool of regionally available providers. BCCFH hired physicians, physician assistants (PA), and nurse practitioners (NP). The PAs and NPs needed a minimum of 2 years of work experience and were supervised by a physician. In the second surge, the admission criteria of BCCFH expanded to provide care to patients requiring a higher level of acute care like remdesivir, steroids, and so on. This prompted the recruitment of providers with higher acute care experience like hospitalists during the second surge.

2. 2. How many to hire: At BCCFH, the following roles were identified for providers: a triage physician at each shift, providers for rounding and admitting during the day shift, and cross covering and admitting providers overnight. BCCFH aimed to hire 65 FTE to cover 250 beds at the field hospital. This was based on the staffing ratio for 2 providers per 30 beds for a 12-hour shift. Previously, the alternative care site plans from other US states have suggested at least 2 providers per 50 beds for 12-hour shifts. ^7,9 The clinical leadership, that is, CMO, ACMO, and nursing leadership made the decision about the staffing ratio at BCCFH. The leadership considered that there was limited information available about the course of COVID-19 in March 2020. The early reports from New York suggested some patients may have rapid deterioration of their clinical and respiratory status necessitating more staff. ^{Reference Goyal, Choi and Pinheiro10}

3. 3. How to hire: Like the “pro re nata (PRN) staffing” models used in many hospitals, all providers were hired under as-needed basis to consider ever-evolving staffing needs based on the actual or expected patient census in the field hospital. ¹¹ Key personnel with critical skills, such as certified registered nurse anesthetists, who constitute a scarce resource during the pandemic, were hired under a contract with fixed working hours.

Step 3: Mass Outreach

At the initial phase of the pandemic, there were concerns about frontline clinicians’ non-availability due to sick days, COVID-19 quarantine, competing clinical responsibilities elsewhere in the region, burnout, and mass breakout among staff members. Additionally, the nature of the public health emergency might deter some from working in high-risk environments. ^{Reference Gohar, Larivière and Nowrouzi-Kia12} To address these challenges, the CMO, ACMO, and the communication team devised a mass outreach strategy with 3 underpinning principles.

1. 1. “No-Pull” policy from regional acute care hospitals: In discussions with stakeholders at JHM and UMMS, there was a concern for frontline provider shortage. Given these concerns, the BCCFH leadership decided not to hire staff from the front lines in acute care settings (hospitalists, intensivists), to minimize the institutional shortage of clinicians.

2. 2. Target trained workforce regionally: It is important to point out that, while there was an escalating need for acute care health care workers regionally, there was a concurrent increase in furloughs of health care workers in non-acute care settings. ^{Reference Gooch8} The regional urgent care and primary care providers were the bulk of the applicants who were subsequently hired at BCCFH.

3. 3. Non-traditional outreach: Traditionally internal referrals, third-party recruiters, advertisements in journals, job fairs are among the common sources of applicants. With the constraint of time and the scale of recruitment, non-traditional strategies were used to reach to a large pool of potential applicants. These included leveraging existing networks with local leadership to send recruitment emails to their staff, focused outreach to groups on social media, print and radio advertisements, the social network of the hired staff, and email the member list of the Maryland chapter of the Society of Hospital Medicine.

Step 4: Streamlined Candidate Tracking

A centralized application email and a candidate relationship management software were used to manage the large volume of applicants in an expedited, effective, and efficient manner. The software was available to the recruitment team through one of the partnering institutions (JHM). Specific aspects of this strategy are as follows:

1. 1. Centralized contact email was used by all applicants for submissions and follow-up communication.

2. 2. Initial application requirements were concise, and the applicant only needed to submit curriculum vitae and medical license.

3. 3. Applicant Tracking System (ATS) or Candidate Relationship Management (CRM) software solution allowed to build customized algorithms to match the appropriate candidates, broadcast emails, schedule interviews, and track applicants’ progress through the next steps. The partnering institution, JHM, already had CRM access internally and was made available for BCCFH’s use at no additional cost. This step was critical to expeditiously navigate the rate-limiting step of sorting through applications.

4. 4. Shared spreadsheet for applicant information: A live online spreadsheet with details of potential interviewees was designed by the communication team and securely shared across the other teams. Each team updated the progress of the applicants in the hiring process in the spreadsheet. This significantly reduced the burden of email exchange amongst team leaders. The spreadsheet allowed to track each applicant’s progress through each step and troubleshoot applications with slow progress time.

Step 5: Pre-Interview Screening

Virtual or phone screening using a pre-specified questionnaire (Supplement) was employed by the recruitment team. The screening questionnaire was developed by the communication team in consultation with the interview team. It was developed to effectively screen applicants who did not have the required credentials for BCCFH. It included questions about their training, clinical experience, medical license, agreement to compensation, and brief questions about the background. This step mitigated resource waste by avoiding the downstream interview, occupational health visit, credentialing, and human resources processes.

Step 6: Interview With Non-Traditional Goals

The interviews were conducted virtually by the interview team (CMO, ACMO, and medical director). During the interview, the interview team assigned each applicant into 1 of 3 categories (red, blue, or yellow) at the end of the interview, based on their acute care experience and expertise. The red category included providers with significant acute care experience, the blue category included providers with intermediate acute care experience, and the yellow category included providers with no or limited acute care experience. Given the diverse background, training, expertise, and experience of all applicants, the interview team created innovative team structures to utilize all available expertise. Triage was assigned to a red provider only during day or night. The day shifts were staffed with a minimum of 2 red providers. For rounding, the providers were paired in teams based on the color categories. A yellow category provider was always paired with a red category provider. A blue category provider could be paired with another blue or red category provider. The red and blue category providers were preferred for night shifts. The night team always included at least 1 red category provider. The providers with acute care experience, familiarity with the electronic medical records (EMR), and flexibility in their availability and roles were preferred during the interview. Providers who had regular availability were desirable for day rounding shifts to maintain patient care continuity. Potential candidates for the role of the medical director were also identified during the interview. These included providers who had prior administrative experience, or managed practices, or had additional training experience in public health.

Step 7: Concurrent Background Check, Credentialing, Occupational Health Screening

Credentialing and occupational health screening were performed concurrently. The credentialing team had more than 10 years of experience in credentialing physicians through JHM. The credentialing process required limited information and forms from each applicant. The applicant was asked information about their medical training, state licensure, DEA licensure, and board certification. The providers were enrolled into Medicare, Maryland Medicaid, and other commercial payors. The executive order by the Governor of the State of Maryland waived some local and state statutes for the licensing and credentialing of health care workers. ⁴ The executive order allowed for interstate reciprocity of health care licenses, allowed an expanded scope of practice for health care practitioners with supervision, and allowed inactive practitioners to provide health care services without first reinstating their license. The governor also ordered the secretary and all boards and commissions to expedite all requests from inactive practitioners to reinstate inactive licenses. Background checks were performed for all providers and outsourced to a third-party vendor through JHM. For occupational health screening, appointment time slots for N-95 fit testing, and infection control practices training (eg, donning and doffing, cleaning of equipment) were expanded to ensure adequate availability for all providers.

Step 8: Focused Onboarding

Once providers were ready for scheduling, they were provided with onboarding materials. The welcome letter contained information about parking, access to the website for signing up for shifts, a tip sheet, and video modules of the EMR and the communication application used in the hospital, information about security, and nearby hotels. It also included information on training like fire safety and the online death certificate completion process in Maryland. Prior competencies were accepted in place of HIPAA (Health Insurance Portability and Accountability Act) and compliance training. While this is not ideal in traditional hiring, the added benefit of this training was weighed against the time delay for onboarding providers. For scheduling, the providers were able to denote their availability using the SignUpGenius® website. The scheduling team made final assignments based on need, team structure, and continuity of care. For the first shift, we used a “buddy” system, where each provider was paired with another experienced provider to orient them to the workflow and EMR. This allowed for a hands-on orientation as well as a seamless transition into the team.