a16z Podcast - Nursing Today, From the Bedside and Beyond

Episode Date: November 28, 2019

"Constant attention by a good nurse may be just as important as a major operation by a surgeon”, diplomat Dag Hammarskjöld once observed -- and that may be more true today than ever before. For most of us, nurses are essentially the face of the healthcare system: the person you’ll see the most of while you’re in it, who will monitor your vitals, administer medications, hold your hand when you’re in pain or scared, answer all the questions you forgot to ask the doctor.So in this episode, we take a look at the role of that unsung hero of healthcare -- the nurse -- at an industry level. Iman Abuzeid, CEO and co-founder of Incredible Health (a hiring platform for nurses), and a16z general partners Julie Yoo and Jeff Jordan discuss with Hanne Tidnam how the scope of the job is changing today and why; what’s driving the looming nursing shortage crisis, and ways we can help solve it; what it’s like to build a new marketplace platform in healthcare; and how best to introduce innovation into the healthcare system overall.

The content here is for informational purposes only, should not be taken as legal business, tax, or investment advice, or be used to evaluate any investment or security and is not directed at any investors or potential investors in any A16Z fund. For more details, please see A16Z.com slash disclosures. Hi and welcome to the A16Z podcast. I'm Hannah. For many of us, nurses are essentially the face of the health care system. The person you'll see the most of while you're in it who will monitor your vitals, administer medications, hold your hand when you're in pain or scared, answer all the questions you forgot to ask the doctor. In this episode, we talk all about the role of that unsung hero of the health care system, the nurse. Iman, Abuzade, CEO and co-founder of Incredible Health, a hiring platform for nurses, and A16Z general partners Jeff Jordan and Julie Yu on the Consumer and Bio Teams, discuss with Hannah Tidnam how the scope of the job is changing today and why,

what's driving the looming nursing labor crisis and all the ways we might be able to impact that, what it's like to build an innovative marketplace platform in healthcare and how best to introduce innovation into the health care system overall. So we're here today to talk about the role of the healthcare worker and specifically the role of the nurse. We've all of us, I'm sure, interacted with nurses. I think we have a sense of what the job looks like when you're there in the doctor's office. But can we zoom out a little bit and talk about what the job looks like from an industry level? So there's a lot of clinical workers in healthcare and it's a very labor intensive industry. And so as of, say, like, 2018, I became the biggest industry in the U.S. in terms of number of workers.

And it's a very labor-intensive industry. So the majority of those workers are nurses. So 60% of clinical workers are nurses. Oh, my gosh. That's a really high percentage. It's a really high percentage. How many nurses are there in the United States? So there's 3 million nurses in the U.S.?

That's like 1% of the U.S. population. And when you say labor-intensive, do you mean physically labor-intensive or hours? What do you actually mean by that? What I mean by labor intensive is you need a lot of workers to deliver the care in the same way a restaurant is labor intensive. They're team players. They're involved when patients are entering the hospital or health care facility during their entire state and also during discharge. They make a huge impact on the patient's experience while they're in the facility. Nurses are kind of the engine of how hospitals and clinics work. When you think about an encounter as a patient, the number of minutes that you spend sort of interfacing with any of the health care workers, the vast majority of those minutes are likely to be with the nurse.

nurse. It's on admission. Even the upfront triage, you know, when you get referred to a facility, oftentimes that first point of contact where they are trying to qualify where in the hospital should I even send you sometimes is a nurse because of the need to actually clinically understand what is happening to you as a patient. The doctor is typically kind of the primary type of provider that one thinks about when interacting with the health care system. But oftentimes the physician is actually the one that you spend the least time with in a health care encounter vis-a-vis a nurse. Absolutely. Yeah. So when you say labor intensive, what does that actually break down to? How many patients for how many nurses? Yeah, it's funny you bring that up because that's a really controversial topic. The topic of staffing ratios, how many patients to a nurse? So in the state of California, it's actually regulated and it's five patients to one nurse at any given time. It'll vary by unit. So for example, in the intensive care unit, it's more like two patients to one nurse. But California is one of those rare states that, you know, we're just a little bit more regulated here. there are nurses all over the country fighting for staffing ratios. Because when you have too many

patients to one nurse, your quality of care goes down, nurses get burnt out. A nurse who's working beyond the 12-hour shift, right? They're on hour 15, 16. The research shows they are 2.5 times more likely to create a medication error. There's also research that shows when you're understaffed, your patient mortality goes up by 4%. So the patients are literally more likely to die when a hospital's understaffed. It's a really challenging problem. And that's not regulated as well. It seems like if you're regulating the ratios, like you would not be regulating the... It should be, but, you know... They regulate truckers but not nurses.

So let's actually talk about the scope of the job. What does that look like today? The job is changing in clinical terms. Is it also changing in other ways? There's increasingly more and more administrative work to be done just because of the way, you know, hospitals bill and the way medical records work that, you know, things have to get recorded. So also for a bunch of liability and malpractice reasons, you know, you also have to record everything.

And so the nurse is heavily involved in documents. documentation as well. Which also involves a reimbursement, a pretty core function for both the patient and the provider. And anything reimbursement related, oftentimes that's viewed as something that is sort of below the pay grade of the physician. Health plans and insurance companies oftentimes are employing droves of nurses for things like prior authorization and sort of medical necessity assessment because you do need to literally review the notes around that patient encounter to determine whether or not it is something that should be reimbursed under of those medical circumstances. And right now, there's not a great way to sort of automate that

process. And so it does require human judgment. And oftentimes, again, those folks are nurses because it's expensive to do it with a nurse, but it's even more expensive to do it with a physician. And so it's sort of the lowest, you know, sort of a level of clinician that you can still have that judgment, but do it in as cost effective of a way as possible. So we're in the middle of a big nursing shortage. There's been a lot of coverage about this looming crisis in nursing. And I understand the regulation to make it so that nurses aren't handling 25 patients at one. But why are nurses in such short supply? Our demand for health care as a country keeps going up as our population ages. Drawing demand, not enough supply of workers. The nursing shortage is a number one skilled

labor shortage we have in this country. And it's estimated that by 2024 will be one million nurses short. The shortage of workers is estimated to be three times larger than the shortage of engineers in the United States. So I mean, these are big, big numbers. Are there other reasons as well besides just the growing system? Are there things specific to the job that people are not bringing in more talent? The other reasons that kind of just exacerbate the situation is one, nursing schools are not able to take in as many students as they would like because their faculty is also retiring. You know, the biggest group of nurses right now is millennials, but the second biggest is the baby boomers. So it's expected that 20% of nurses are

expected to retire in the next three years. And that includes not just the nurses on the floor or in the units, but also the nurses who train other nurses in nursing schools. So there's also a shortage of faculty, too. There's also geographic mismatches where there are acute shortages in certain places. But it's prevalent throughout. So even in all the big cities, whether it's New York City, L.A., San Francisco, they are all suffering from shortages. So does that mean it's a good career to get into because you're highly desirable? It is an amazing career to get into for job security. It also pays quite well. And because of the labor shortage, the compensation does keep moving up. So for example, in California specifically, the average salary for a nurse

is $100,000. In the Bay Area, it's closer to $140,000. In L.A., the average is $120,000. It has traditionally been looked at as a blue-collar job, but they're getting white-collar compensation now. And it does require a degree. It does require training and certifications. So you have OR nurses, ICU nurses, emergency nurses, oncology nurses with more expertise, with more certifications, with more training in specific areas. So I think, you know, there's a perception that it's blue collar, but it's actually not. I mean, it's a pretty rigorous curriculum with certifications and tests and things like that. I've talked to a number of young people who are considering a career in nursing and they're like, I know it's going to be hard work. I know it's going to take a long time. But, you know, the prize at the end is rewarding. Actually, what does that look like? How much education? How much certification?

Yeah, so the usual degrees are either the BSN, the Bachelor of Science in Nursing, or the Associate's degree in nursing. The associate's degree is kind of falling out of favor as hospitals increasingly require a bachelor's degree. And then even after the degree, you start working, but you are also training and or specializing in specific units as well. And is that degree falling out of favor because nurses are doing more and hospitals want nurses with a higher degree of education?

Yeah, you just stumbled on a number. really controversial topic. There's a certification for hospitals called magnet, and one of the requirements to be magnet certified as a hospital is to have, you know, the majority of your nurses with bachelor's degrees. So like many, many things in health care, because it's a regulated profession and a regulated industry, but it's also an industry that they're very big on brands, and it's yet another stamp that a hospital or an academic medical center can get. Okay, so the hospitals are getting, like, squeezed by the regulation and then also by this increasing demand for a certain level of expertise and the nurse's job is growing. What is the bottom line for hospitals at the

moment? How are they dealing with this kind of increased pressure? Yeah, so here's the bottom line. When you're understaffed or when you don't have enough nurses, you end up spending on overtime, on contract workers, and you can't see as many patients. So this whole issue that... So higher costs and lower revenue. Exactly. Other than that, it's not an issue. Exactly. Higher costs and less revenue. And it is probably the number one issue for hospital executives, staffing is, and it's definitely certainly their number one cost. And the thing to keep in mind is that hospitals are thin, margin businesses.

The average margins is 3%. That's interesting because I think the common perception is that hospitals tend to be places with huge, high-volume financial flow. Cost structures are so high that it's hard to operate in the black. I mean, the other thing that's contributing to a lot of this is, you know, we talk a lot about the unbundling of the hospital and the fact that a lot of the kids. care that used to require coming to a hospital is now being provided sort of out in the communities and urgent care clinics and, you know, retail type settings. And many of those clinics

are actually staffed by nurses. And so, you know, at the same time as you have these shortages sort of in the traditional care settings, you also have more demand coming from these sort of alternative sites of care that are designed specifically to be staffed by lower acuity providers, not physicians. And the whole purpose of those care settings is to reduce costs on the delivery side, but it's just this sort of vicious cycle where that's also contributing to higher demand for this kind of skill set. What does that process look like today for the profession of finding the right job, you know, the right hospital, the right clinic? Yeah, it's pretty broken right now. So if you're looking for a job, for example, as a nurse, you have to apply to probably

10, 15, 20 places. And most of the time you don't even hear back. And if you hear back, it could take months. But why? If they need them so badly, I don't understand. It seems so. So we talked a lot about the shortage and the under supply, but the other thing that kind of plagues this industry is inefficiency. And the talent acquisition teams or HR teams inside hospitals are armed with pretty outdated tools and processes that really haven't changed since like the 90s. And they're primarily using external job boards like Indeed or LinkedIn or their own hospital's job board, put a posting out there and hope something happens. That's really difficult when you are going after a group of workers that are in high, high demand. And so you're basically waiting for the right

people to come. And it's really quantity over quality. So when people apply, the HR teams are manually sifting through all of those applicants and manually matching them as well. And so that just creates an insane amount of inefficiency. At any given time, one hospital recruiter is trying to fill 100 jobs. Another contributor to inefficiencies on the health system side are really when patients come in, you know, how do you sort of effectively match demand to supply? And today, that's done in a fairly brute force way. You know, there really aren't technology tools with intelligence that allow you to route and triage patients to the right type of provider or the right type of nurse or even distinguish whether or not a patient is appropriate to see a nurse versus a doctor.

And that's one of the highly evolving areas of the market right now is the scope of practice concept where, you know, things that maybe used to be only possible to do by a physician, increasingly those boundaries are being redrawn, and nurses are taking on a lot more of that, but that's not yet reflected in sort of that routing logic, so to speak. And so you often will end up with situations where, you know, a patient will end up waiting eight weeks to see a physician when, in fact, that person likely could have gotten in to see a nurse much sooner, and that has not only, you know, clinical implications, obviously, for the patient, but operational inefficiency implications for the physicians in the hospital system

where that doctor is not being effectively utilized for their unique expertise. expertise versus a lower sort of acuity provider. And then for the health system, they're losing out on potential revenue if, again, if those slots are not being fully utilized to their full extent. I just had this happen to me last week. My doctor was unavailable for two weeks and the nurse practitioner would see me the same day. Yeah. And there are real sort of societal and cultural challenges with that. I think Americans are not yet fully bought into sort of going to a nurse for something that they think they should go to see a doctor about. And we hear that all the time in the market. In fact, it might be better to go to a nurse for certain things

because you are going to get a different level of empathy, a different level of care and support and service. And so that's also contributing to this. But that's sort of the notion of the most effective use of clinical resource, I think is a big component of the challenge here. The process is largely the same way it was a generation ago. It's a paper-oriented process because the tech tools don't really work for something this specialized and this unique. So, you know, the dominant job platforms are LinkedIn and ZipRecruiter. But they're not engineered to, have this level of specificity and this granular of matching. You know, they're not checking licenses and credentials and certifications and aren't set to match those with existing job openings because the horizontal platforms kind of fall prey to the least common denominator factor. Can you explain a little bit more about what you mean by that, Jeff, that the horizontal platforms fall prey to

the least common denominator? If you're trying to fill everything from a CEO to a sales rep to you know, oncology nurse, you're not going to have the same certifications, clearly for the CEO for the nursing. And that general purpose tool does not work well for that highly specialized vertical. We see a natural progression that tends to repeat over and over where, you know, one horizontal platform serves the needs of multiple verticals. eBay, you know, started as trading collectibles, but then they added computers and sporting goods and clothes and, you know, and cars. We even sold an airplane when I was there, a Gulfstream. And so the same thing, you know, platform is being called, in this case, to service all the needs of that vertical.

And early on in platform development, that typically is sufficient because it's so much better than the analog alternative. But as these platform gets big and the individual verticals on that platform get big, there's an opportunity for Nucos to come in and better serve the needs of that vertical relative to the one-size-fits-all. For example, Stubbubb came along and did a highly tailored offering for the resale of secondary tickets. They had time and energy and site space to do things like ensure electronic delivery of tickets, you know, have a trust and safety function for if the ticket didn't work when you got to the venue. And as a result, StubHub was able to build a big business in the secondary ticket market, taking a lot of that business away from

eBay. Right now, Stockex are doing collectible sneakers. You know, Poshmark is doing apparel. And each of those is building verticals that, in some cases, taking one of their verticals and doing it better. So what do we need to see then if we're to better serve the needs of this specific vertical? To be honest, most healthcare workers are not on LinkedIn. And then that makes the search and discovery for the employers very difficult. And the search and discovery fields, you know, they're not healthcare specific either. And then you have the in-mail product that the response rate is like, it's less than 10% the response rate on in-mail. So there's a lot of improvement needed.

So high signal is better than load signal. So now you're in a narrow vertical, one job description, and the complexity and optionality is enormous. How could that horizontal platform begin to address it if it's highly challenged in a highly constrained environment to address it really well? So, I mean, that's a lot of the thesis is it takes that level of focus, specialization, maniacal optimization to add value to the health care system and to the, nurses that, you know, that helps bridge the scamp. So if now is a moment for the health care

vertical to kind of be better addressed, what does that actually look like in tactical detail? We've done three or four things that are specific for this industry. Number one is that the employers apply to the talent instead of the other way around. We get away with that because there's such a big shortage. And honestly, that's what's needed given the supply, demand, and balance in this market. The second thing is we've largely automated the screening things like licenses and certifications and experience and skills, all of these things that the hospital usually does manually. By using technology, you can just deliver a lot higher quantity and quality of talent to the employers. A highly curated sample based on their specific need. Exactly. And so then

the third piece is the custom matching, right? So it is not helpful for a recruiter to log into their web application and see 200 candidates. They need to just see the 12 out of the best fit. Right. No, 200 just makes you want to close it again. Go do something else. Think of the gains the hospitals. if you, all of a sudden, the process goes from a torrent of inbound to highly curated sample. The number of resumes you review goes way down. The number of interviews you do typically goes way down. The time to hire goes way down because you've got that curated sample of qualified nurses for this specific position you have. You are creating a very high level of operational efficiency for the administrator at the hospital.

And that administrator is very, very busy. And it's the same experience on the talent. The nurse does not want to hear from 80 employers. They want to hear from the three that are the right fit. And so building those custom matching algorithms are really important. They drive the experience and the efficiency for both sides as well. And then the fourth piece, we provide pretty robust data analytics to the employers where they can see their utilization and their hiring process and they have a lot more visibility into it. And they can even see the number of days.

Talent is spending between each step. And they're able to benchmark that against their competitors because their competitors are also using our platform. So just shining a light on that kind of black box where things would languish in weird limboes for a super long time. I mean, just like any industry, any function, a lot of decisions should be based on data. And HR and talent acquisition is a function that has an insane amount of data, but sometimes it's hard to get at. And that's what decisions should be based on how they can improve their internal hiring processes. Can you talk a little bit about how this actually affects the bottom line of hospitals and providers? Like, how does making a specific search field for certification actually turn into dollars saved?

Hospitals and health systems are able to hire and fill those roles for permanent nurses in less than 30 days, where that national average is 90 days or longer. That results in significant, like millions of dollars in cost savings for the hospital because they're not spending on overtime. They're not spending on contract workers. Yeah, and healthcare is notorious for it being a very, very challenging place for technology companies to prove ROI. And this is one of those areas where there's such a clear top line benefit because you can, can literally say my patient volumes are hurt or benefit from being able to hire nurses more

quickly. And higher revenue, because you have the capacity to take on the business you need. The other place where the revenue piece shows up is just in terms of patient access, you know, one of the crises in this country is the fact that patients cannot access care because of these supply constraints. It goes back to this notion of kind of right-sizing care if you are a patient who had, let's say, elevated PSA. That is a fairly wide spectrum of clinical, you know, may actually warrant going straight to a urologist versus you might have to be worked up and kind of go through a care journey. If you were not doing this appropriately, you would essentially be sort of closing the door to patients because you were making them wait. The patient wouldn't

get the clinical benefit and then you were losing out on that revenue stream. And frankly, the physicians, you know, they would always say, I'm optimizing for surgical yield. I want a mix of patients who are most likely to result in a case that is going to take advantage of my unique skill set. And so even from a physician retention, satisfaction, et cetera, that perspective, that was a huge issue that these organizations were trying to deal with. Did nurses get to optimize for anything like that as well? Oh, absolutely. No, I mean, it's the same thing where I think for nurses and even MAs and some of these other, you know, types of roles that have sort of popped up to kind of support the administrative overhead. You started to see, again, the administrative

tasks be passed on to these folks who are very legitimately trained in clinical practice. and we're taking on these sort of lower utility tasks. How can technology sort of effectively route people so that some of that burden disappears? So when you're creating a jobs marketplace like this where you're matching up this like highly vetted, highly curated with all these different requirements and challenges from regulation and certification, how do you think about vetting for the non-obvious stuff, like about empathy, about bedside manner, how do you think about those? That stuff is really important because ultimately the mission of most of these hospitals, all of them probably, is to deliver amazing care, right? And putting all like the hard skills aside, you know, the licenses, the certifications, all the hard skills, there is a whole set of soft skills that people need to convey and practice when they're on the floor as well. We have an entire

interview preparation kind of like module basically that helps nurses convey their softer skills in interviews. What are they motivated by? Are they truly motivated by patient care or not? How much empathy do they have? What are their motivations? What do they want to do with their career. We've taken a much more like hands-on approach with just like, hey, these are the things that you need to just really convey in your interview. What was the most challenging thing for you to build into the system when you're building these tools from the ground up? I think the challenge of just the heterogeneity of this. So we're dealing with all RNs and NPs. There's multiple specialties and multiple requirements. And then the employers also have lots of different

needs. And when you're trying to build technology that works for that for all the users, it's challenging. The healthcare industry is notoriously difficult to disrupt with new innovation, often for very good reason and because of the complex nature of the system itself. How do you see yourself fitting into an overall trend of new technological innovation in healthcare? Or I guess another way to say that is what has your experience been like introducing a new tech into this particular system? I actually feel a lot of empathy for some of the hospital executives and the administrators and the nurse managers and so on who are trying to manage the operations, right, they're dealing with multiple issues at the same time. First of all, like reimbursements going

down, right? So they had a lot of revenue pressure. Number two is it's actually not completely clear in the healthcare industry or in a hospital who your actual customer is. Common sense would say it's just the patient, but the patient doesn't actually, for the most part, doesn't pay for the care directly, right? So they also have to take into account health insurance, you know, the payers, how they're ultimately making money and how they're getting reimbursed. So that's why you see a lot of the technology investments in healthcare or in a hospital are more around billing than around, you know, optimizing operations, right? And then you also have employers in the healthcare industry who are ultimately also the ones who are paying for the care. And their employers are

offering the health insurance to the employees. And, you know, they're making decisions about what plans to offer. And there's not much clarity on pricing. It's just like a very convoluted industry, right? Where, you know, just like the normal free market forces and competition that we see in other industry doesn't necessarily apply. The stakes are just so much higher than any other industry. You know, if you turn an engineer, you're probably going to lose a little bit on productivity and maybe not ship some code. But here, if you are constantly churning talent and turning over folks who are staffed in these environments, there is such huge risk from a patient safety perspective on that because, you know, these teams have protocols and they have ways that they

respond to sort of emergency situations and whatnot to train and really sort of get up to speed on those types of environments, very complex environments, takes time. If you're not doing that match up front in a way that sort of guarantees or at least raises the probability of longer retention of these employees, then, you know, there's a real high-stakes risk to patients. Actually, let's talk about that retention piece specifically. We've talked about the talent acquisition, but not so much. How do you hold on to good talent? What's the turnover rate like in this profession? The annual turnover for nurses in the U.S. today is 20%. Oh my gosh. Is that because it's so hard or because people move or what?

The number one driver is understaffing, right? Because when you're understaffed, you're burning out your existing workers. And then also it's a really tight labor market. You tend to change jobs more often when there's a shortage. So what happens? You get the job and then you're overworked and you start to become disillusioned and then you think you're going to have a better job elsewhere, essentially? Yeah, there's probably three or four main factors why nurses change jobs.

Number one is like, you know, they're tired and burnt out and just need a different unit or hope for a hospital that's better managed or better staffed. And number two is they're trying to reduce commute times. 90% of nurses are women. Many of them are taking care of children. So many of them are trying to shorten commute times. I can't believe it. It's 90% still. That's so high. Yeah, it's still high. And then career advancement is another reason. So if you're trying to grow your skill set, become more specialized and you're not seeing those opportunities with your current employer, you're going to change. And then higher pay. It's going to market wages because of supply, demand, and balance. It's funny. It sounds like all the normal reasons, but like super condensed, where you feel them very acutely and it happens very fast. Yeah. Okay. So on retention, what are the things that people can do then besides finding the right job the first time and supplementing the supply so that there is not a critical shortage and you're working way long hours? What are other things that employers and hospitals can do to solve that piece of the problem? The few factors that influence it and the hospitals that have the best retention do this extremely well. Number one is fast hiring. So it turns out if you have an amazing candidate experience while you're getting hired, you are more likely to stay around.

Really? Even if you get disillusioned a little bit later. Because that's part of it. Well, you get a disillusion before you start. That's usually not a good leading indicator. That's true. That's true. You're hired in 11 days.

You have a very positive impression of that employer. Like, oh, my goodness. Like, they have their act together. And then that leads to higher employee engagement scores and more likely to them to stay. I was talking to multiple venture capitalists when I made the move for being an operator to a venture firm. The first talk to me, the recruiting cycle was over six months before an offer came. The offer only came after I started talking to Andrewson Horowitz and got to an offer within a few weeks. And then the six-month person said, oh, we'll move fast.

And so I was so disillusioned at that point, it was a pretty easy decision. Yeah, it's very telling. What have we learned from these other platforms that we can incorporate into the platform that's better addressing a specific vertical? What is some of the kind of knowledge that does apply? So we use these competitive tactics, right? When a hospital recruiter logs in, they know they're competing with other employers at the same time. There's a time limit. You gamify it?

Yeah. That's awesome. There's a time limit. There's a seven-day countdown for them to send their interview requests. And they can see which candidates are popular. So we're creating urgency and scarcity and competition. That's at e-commerce. To only one left, you know, kind of thing.

It works. So how is the adoption of this kind of thing? Like, do you hit resistance along the way in certain areas? Is there friction to getting these new platforms integrated into the system? Okay, so this goes back to what Julie had said earlier about ROI and the value proposition. You have to have a really, really strong value proposition and ROI. And whatever you've come up with has to be at least 10 times better than what's already out there. So whatever we come up, Incredible Health, it needs to be at least 10 times better than LinkedIn or Indeed or any of these other.

schools that they're using. We now have over 150 hospitals in California using our platform in less than 18 months, very short sales cycles because this is a, you know, hair on fire problem. The CEO and everyone in the C-suite cares about staffing and getting great talent and getting amazing nurses in permanent roles quickly impacts their bottom line and both revenue and cost. That's the other, you know, sort of case for why you need vertical solutions is the supply side of the market also has to believe that they are going to be better represented on this platform than your sort of generic horizontal platform and that there's something new to offer there. So what are you seeing on the response from the nurse's side? Yeah, it's similar in that

the value has to be really clear to them as well. Right now, we're the only platform out there that says, create a profile, sit back and relax, employers are going to apply to you. So employers send them interview requests and then the nurse gets to decide which ones to accept and which ones to decline. And what that does is it gives more control to the nurse. And this is something that they do not normally experience. Yeah, it sounds like a profession rife with a feeling of lack of control, actually, that you're constantly being told what to do and where to go. Yeah. This is a highly mistreated and underserved group of workers. The vision is to help them live better lives. It's about the healthcare professionals. Whoever creates a product or an experience and treats

this group of workers the best, appreciates them, celebrates them, gives them an amazing experience. All of that is going to win. That's interesting. I blogged years ago about in two-sided marketplaces, is the consumer side is the one that you should have to optimize for, even if the institutional side is the one that pays you. You know, at eBay, you optimize for the buyer, at Open Table, you optimize for the diner here. You optimize for the nurses. The folks in the recruiting office of the hospital are actually consumers, right? And they're going to go home, and they're going to use their iPhone and shop on Amazon

and have these magical experiences in other parts of their lives. And then they get to work, and they have these sort of highly legacy ossified archaic systems that sort of overall trend is what's driving, you know, a ton of uptake of these novel technology solutions. A few of the hospitals use Oracle PeopleSoft. Some use Taleo. Some use, you know, there's lots of different software, whether they're applicant tracking systems or more general HR systems. And we're there and they're like, oh, I have to use a 20-page manual to create a job wreck. Oh, my gosh. Right? And you look at it and it's like, oh my God, this software looks like it's from like the 80s. Like when software was first like a thing, right? And so when we come in, we've even had chief nursing officers say, like, oh, wow, it looks like a dating app, right?

I was going to say that earlier when you were talking about. Yeah, match.com for nurses and hospitals, right? And so. Without the fake profiles in spin. Yes, without that. Yeah. Certainly a lot of the features we've built into the platform, we've borrowed from consumer apps, like the countdown timers and who's popular and kind of creating urgency and scarcity in the platform and just simply making it beautiful and easy to use. You see now, for the first time, really grounds up demand from clinicians asking for better tools.

They no longer are able to deal with kind of these legacy EHRs that have been implemented across the industry. One of the challenges has been, it is just so damn hard to sell to these organizations, right? If I'm looking at two options as an entrepreneur, either I build software that I need to somehow figure out how to distribute to this industry, make them change the way that they operate, you know, deal with thousands of employees at these organizations. that all have their own agendas versus, you know, building sort of outside of the system, let's say a full-stack primary care clinic that I can build my own technology from the ground up, eat my own dog food. And therefore, the packaging of that offering may look like a direct-to-consumer offering, but at the end of the day, I'm trying to solve the same problem, just, you know, sort of from the outside. And so those are the two attack vectors that we see out there.

I totally agree that in some ways the clinicians are sort of the forgotten end users of this whole thing. And you see a lot of emphasis on the patient. But at the end of the day, the high leverage point is actually putting better tools in the hands of clinicians. Yeah, I mean, I meet many founders who are working in the healthcare industry and they're usually building applications that are patient facing, which is great. But I don't see enough working on the back end of healthcare. We took one part of it, which is staffing. There's certainly a ton throughout operations. And there's a lot of innovation needed in basically the full stack of healthcare. So what kind of takeaways or advice would you have for other founders building companies

in the particularly challenging space that is health care. Like many things in entrepreneurship, timing is everything, right? The healthcare industry is at a point where the cost pressure has never been more intense because reimbursements are going down. And the competition is fierce among providers. And that creates opportunities for entrepreneurs and a bunch of hospital executives that may be willing to listen. And so when you're creating your product,

you need to come up with something that's at least 10 times better than what's already out there. Like at least 10. And you can measure that however you want, 10 times better, 10 times. cheaper, 10 times more efficient, 10 times faster, like whatever it is, and have a really, really strong value proposition that clearly ties to ROI and impacts the bottom line for the hospital, clearly impacts it, not like indirectly, but directly impacts it. That's awesome. Thank you so much for joining us on the A16D podcast. Thank you. Thank you.