Following COVID, turnover across our emergency department registration teams was exceptionally high. Leaders were spending so much time filling vacancies, interviewing, onboarding, and covering shifts that they had very little time left for coaching or developing their teams. Every new hire required roughly six weeks of training, so as soon as one person became productive, someone else was leaving. We had almost accepted high turnover as part of an entry-level role, but the operational strain and impact on morale made it clear we couldn't continue operating that way. 

The program was designed as a sustainable talent pipeline within Revenue Cycle Operations (RCO), one that develops leaders who understand how decisions at one point in the cycle impact financial performance, compliance, and patient experience downstream. From the start, the goal was not just education, but readiness: preparing fellows to step into high‑impact roles upon completion of the program.

The turning point came when we looked beyond staffing numbers and asked what was preventing our leaders from being successful. Our leaders were stretched thin, particularly after COVID, and we realized turnover wasn't simply an HR metric—it was limiting our ability to support employees, deliver a consistent patient experience, and maintain operational performance. Once we recognized the broader impact, retention became a strategic priority for leadership, not just Human Resources. 

The biggest surprise was that many of the reasons employees were leaving were things we could influence. Exit interviews consistently showed employees were leaving for physician practices where they earned similar pay but had more predictable schedules, weekends and holidays off, and lower stress. We also realized we had overlooked opportunities to better support our leaders and create career paths for employees who wanted to stay and grow. 

The first step was presenting leadership with the financial case for differentiated pay in the emergency department. Once that was approved, employees saw that leadership was serious about investing in them. From there, we standardized behavioral-based interview questions, involved frontline staff in hiring, redesigned onboarding, created competency assessments, assigned preceptors, and established a more consistent training experience across all locations. Those changes built confidence that we were committed to setting employees up for success. 

It was one of the most important factors. Employees wanted leaders who were visible, approachable, and engaged—not only when something went wrong, but consistently. Building relationships, rounding regularly, maintaining open communication, and making time for one-on-one conversations created trust and helped employees feel supported both professionally and personally. 

Rather than focusing solely on filling vacancies, we focused on creating an environment where people wanted to stay. That meant improving compensation where appropriate, hiring for cultural and behavioral fit, strengthening onboarding, providing consistent training, investing in leaders, and helping employees feel like they were joining a team rather than simply starting a job. 

 Open positions created a cycle where remaining employees worked more overtime, leaders had less time to coach, and new hires constantly entered training. The emergency department environment also presented unique challenges with unpredictable schedules, high patient volumes, emotionally difficult situations, and complex registration requirements. Over time, those pressures affected morale and engagement. 

 We intentionally included frontline employees throughout the process. Team members participated in interviews, helped improve onboarding, provided ongoing feedback about workplace challenges, and shared ideas during regular conversations with leaders. We wanted employees to know their voices mattered and that they had a role in shaping improvements, not just adapting to them. 

 Absolutely. We recognized the unique demands of emergency department roles and adjusted compensation accordingly. We standardized onboarding across locations, implemented competency testing, assigned preceptors, developed consistent education materials, and reinforced that onboarding wasn't simply about learning systems—it was about helping employees feel welcomed, supported, and connected to the team from day one. 

 We moved beyond annual performance reviews and implemented monthly one-on-one meetings between employees and their supervisors. Those conversations included performance, but they also focused on career goals, personal development, workplace challenges, and recognition. Employees wanted regular feedback, and those conversations helped strengthen relationships, identify concerns early, and reinforce that leaders genuinely cared about their success. 

We invested in preparing employees for those situations through de-escalation training, workplace violence prevention, and organizational development programs. We also created emotional support resources, including debrief sessions after difficult events. Supporting employees wasn't viewed as separate from performance—it was essential to helping them provide compassionate, consistent care while maintaining operational excellence.

As workforce stability improved, we saw measurable operational gains. Teams became more focused on registration accuracy, eligibility, denial prevention, work queue management, clean claim performance, point-of-service collections, and consistent patient communication. Frontline staff also became more involved in revenue cycle and clinical improvement initiatives because they understood the impact their work had across the organization. 

 Retention isn't something you solve once—it's something you continually invest in. We continue reviewing onboarding materials, updating education as payer requirements evolve, maintaining monthly one-on-one meetings, rounding with staff, listening to employee feedback, and looking for opportunities to support career development before employees begin considering leaving. 

Don't accept turnover as "just part of the job." Take time to understand why people are leaving, listen to your employees, and invest in your leaders. Many improvements don't require large-scale initiatives—they come from building relationships, communicating consistently, hiring for behavioral fit, strengthening onboarding, and creating an environment where employees feel valued and supported. 

Leadership matters. Employees' experiences are shaped by the leaders they work with every day. Leaders who communicate openly, follow through on commitments, celebrate successes, involve employees in decisions, and genuinely care about their people build trust—and trust is the foundation of retention. Strong relationships don't just improve workforce stability; they create stronger teams, better patient experiences, and better operational outcomes.