Addressing management issues.

Future of small hospital labs

Q What is the future of the small hospital laboratory? Is "mega-commercial management takeover" an inevitability?

A Alton Sturtevant comments, "Laboratory testing for hospitalized patients will always be needed. The form that testing takes will definitely change over time. Where testing is performed, and by whom, is largely in our hands to determine, based on our actions or lack thereof.

"If we are complacent and do not take control, then testing may move to the nursing or patient-care staff--completely outside of our control. This is not to say that some testing should not move to the bedside or be performed by personnel with specific-only or limited training. If we are concerned about the quality of testing and want to remain in the process, we then should embrace performing testing--based on clinical needs and financial constraints--wherever it is best suited to be accomplished. Be a part of the solution, and do not stubbornly resist change to the point of becoming extinct. Come up with workable approaches to the testing needs of your facility and champion them. Help set up programs and solutions that mesh testing into the hospital as needed.

"A time will come when using a large lab is needed as a supplement to your service, evolving over time, depending on technology, personnel availability, and finances. Be open to all types of these arrangements; do not look at them selfishly but, rather, from an institutional point of view.

"Having a large lab involved can create anxiety--as does all change--but it can also create stability for current staff, if they work within the system. My take-away to you is to do the most that you can to make your small institution successful; and, by doing so, you will ensure the success of your laboratory as well."

Larry Crolla responds, "For the outreach portion of the lab, I do not think this will be case initially. We have to see, however, what the new government healthcare reform will be like. If we go to a system of only a few insurers, then those insurers can dictate in what direction labs will go; most small hospital labs will be out of the outreach business, since they cannot contract for multiple states.

"As far as inpatient testing is concerned, I think the hospitals will do whatever is necessary to keep costs down. If your lab can stay competitive, then you will be okay, at least for the next five years. The problem will come when new equipment is needed. Most likely, the manufacturers of multichannel analyzers will not waste their R&D money to create additional routine equipment with updated technology; pricing for the lab is already approaching that of radiology equipment, which has a better return on investment (ROI). Hospitals will be unlikely to invest in this low-ROI equipment. Labs will be relegated to using the same equipment with new 'skins,' (i.e., color and model number change).

"After a time, only the mega-centers will be able to afford new equipment. Manufacturers will then make equipment to handle large throughput--again adding to the cost because of fewer sales and this specific design demand. That is when the mega-centers will take over and leave the hospital labs to be, essentially, STAT labs. Ten years will be the longest period we could hope for without any of this happening; but, most likely, five to seven years is the when this shift will begin taking place."

Marti Bailey says, "Depending upon the circumstances, the future of some small hospitals might be more secure than you think. Small community hospitals, supported by local residents who place a high priority on having their own hospital, are most likely to survive. I can think of a number of these that have shown relatively strong financial performance due to local support; and as long as this support continues, I see them as likely to maintain their independence. Many of the citizens in the communities I am speaking of are resistant to obtaining their healthcare anyplace except at their local hospital. These same folks would find the sale of their local hospital to a large chain equally unsavory and will continue to offer strong financial support to prevent this from happening.

Bottom line. Our diverse expert opinions demonstrate the complexity of the issue and reflect the volatility of our marketplace and economy. As we head into uncharted waters with a new administration, small hospital managers must stay abreast of new policy and payment rules; monitor payers to know from what entity they purchase business; watch the competition; participate in local activities to know what is likely to happen in a given area (e.g., a large business shutting down); track and replenish equipment replacement costs (not just depreciation); and cater to create loyal customers that will support them in tough times.

Internet surfin' vs. housekeepin' chores

Q We cannot block Internet usage so what are some creative ways to discipline employees who use the Internet instead of contributing to "housekeeping" needs (like stocking the lab area with supplies, cleaning and dusting, cleaning centrifuges, and other such chores)? Many younger employees are lazy and unmotivated to do anything other than the testing work.

A Larry Crolla suggests, "Update job descriptions to include whatever work you require to be done. Contributing to housekeeping activities, inventory control, and whatever else you deem as needed work is now included in all job descriptions. Make all employees aware that these written duties will now be evaluated as part of everybody's performance review. As far as the Internet usage is concerned, you can also make a policy that its use is allowed only for work-related activities and that abuse carries some penalty."

Marti Bailey says, "If you have employees who have enough time to play in CyberSpace, then there is a bigger problem than just inappropriate use of company resources. Research your company's policy on personal use of business computers. Is there a written policy? If there is, get a copy, then read and digest it. If there is not a company policy, then contact Human Resources and/or IT to find out why not and whether an unwritten policy exists that is universally accepted. Contacting managers of other hospital departments to gather their experience with the problem should also prove useful.

"If you have a written institutional policy, then your job is to enforce it. If you are not doing this, then you are negligent. If there is no written policy, then the lab needs to either develop its own or, at least, make a statement that defines appropriate and inappropriate use of computers.

"Once a documented policy has been shared with your staff, it becomes a performance issue for those who choose not to follow it. Any infractions should be documented and the employee counseled. Continued failures to comply with the policy should constitute cause for dismissal. You cannot take a lighthearted approach to this. Employees will learn to follow the policy when they understand that their jobs will be on the line if they do not.

"Identify these 'non-technical' chores and put into place a written record to ensure that they are completed--with all staff members participating. Assign each task to a particular workstation or person in that log so that you can record the date(s) and the person(s) completing the task(s) so that you can monitor compliance.

"Re-stocking of a workstation should be done by whoever is assigned to it. Other chores like cleaning centrifuges have far more serious consequences due to safety and regulatory considerations if not completed and documented.

"All in all, it appears that you need to tighten up your ship. Review written policies with your staff members, who are then expected to follow in order for their performance to be considered satisfactory. Equally important is to review the consequences of failures to follow policies."

Alton B. Sturtevant opines, "Many companies deal with the use of the Internet as a part of their communications or information systems (IS) policies, which cover the laboratory information system, telephone system, voicemail, personal computers, or any of company-provided electronic equipment. Use of personal cell phones, MP3 players, radios, televisions, and other personal electronics are usually detailed in this policy as well. Such a policy usually stipulates when and how an employee should use these devices.

"A discussion of transmission or reception of harassing, vulgar, obscene, or threatening material is usually highlighted to ensure that the employee is well informed with regard to use of either personal or company equipment or systems while at work. If the employee is provided company equipment, then he is informed that any use of said equipment in the manner described here while at work or while away from work is prohibited.

"The policy should 1) assert the company's right and intention of monitoring on an ongoing basis the use of said electronic systems, including the excessive use of the company's Internet system, and 2) state that the company intends to use any currently available monitoring technique to include but not be limited to a) reviewing e-mail sent or received on the company Internet or e-mail system, b) auditing detailed Internet activity, and c) investigating and/or implementing whatever other measures are necessary. Finally, the policy must include the warning that any employee who violates the policy may be disciplined, up to and including termination.

"Speak with your network manager or your IS manager to see what they are doing or can do to help quantify wasted time on the Internet by your personnel. Without specific software measuring systems, you are limited to direct observations. Meet informally and formally with your supervisory staff and other departmental managers, and ask for their solutions and opinions to help with this situation.

"Solicit employee input relating to the issue. Emphasize your company policies. Explain how Internet use can be a time waster and affect productivity. 'Slack' times at work should be used to perform duties such as cleaning and disinfecting the work area, stocking and rotating supplies, performing equipment maintenance, maintaining continuing education activities, reviewing and writing procedures, and other necessary activities that contribute to the well-being of the lab. Document the meeting through published Minutes that are distributed to the staff. The meeting may serve to encourage less unnecessary use of the Internet. Do not expect to eliminate the problem entirely through this discussion. Assign specific personnel to perform the 'slack-time' activities that you have identified as a way of achieving needed functions within your lab, not as a way to 'make work' to justify staff.

"Walk through the lab to observe any activity that would violate any policy. Speak with persons violating the Internet-usage policy just as you would any other bad behavior. Follow disciplinary policy in dealing with violations."

Bottom line. Two issues are involved here: one being personal use of company resources and the second, staff work effort. To address personal use of company resources is to establish limits (or not) in a policy. After a policy becomes effective, it must be enforced. To categorize all younger employees as "lazy and unmotivated" is an admission of the manager's incompetence. The manager should understand what motivates the younger generation(s) and cater to their needs in order to get them involved in housekeeping activities. It is not "rocket science;" it is management.

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Anne Pontius is a senior medical practice consultant with State Volunteer Mutual Insurance Company in Brentwood, TN, and president-elect of CLMA 2007-2009. Send questions to Ms. Pontius at [e-mail].

Edited by C. Anne Pontius, MBA, CMPE, MT(ASCP)