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Laboratory careers: still chances for the brass ring?

For those who work in the clinical laboratory, prospective payment is no longer a distant rumbling in the Federal bureaucracy. It's a full-fledged cold front that's putting a chill on their plans for the future.

As laboratories struggle to coexist with the new reimbursement regulations, staffing is becoming more compact and scheduling more flexible, according to MLO's latest survey of our Professional Advisory Panel. In this climate, many laboratorians are s increasingly skeptical about the future of medical technology, the panel reports.

These observations reflect a widespread trend toward the running of very tight ships. Roughly three-fourths of the labs represented in the survey are subject to DRGs, but the ripple effect is pervasive. A wait-and-see attitude prevails. Laboratorians from large hospitals tend to be the most concerned about declining test volumes and tighter budgets, while panelists from independent--and largely non-DRG labs--are generally more optimistic.

Part I of this special report examines how staff size and makeup have evolved and how lab schedules have shifted to accommodate peaks and lows in workload. In Part II, which follows, we focus on the future of medical technology. The panelists--291 laboratorians at the supervisory level or higher--also make some predictions about their own careers and offer some advice for future colleagues.

* Tracking staff cuts. It is true that many laboratory staffs are contracting, and the number of full-time equivalents (FTEs) may dwindle even further. Figure I shows a current staffing baseline: More than half the laboratories surveyed produce test results with fewer than 40 FTEs. Slightly more than one-third have a maximum of 20 full-time equivalents, while 23 per cent have just one to 10 FTEs.

At the upper end of the staffing scale, just under 10 per cent have an FTE total of 41 to 50; FTEs number 101 to 150 at another 8 per cent of the laboratories. Only 7 per cent of the panelists have more than 150 FTEs on staff.

Staff size has grown leaner for many panelists. Forty-two per cent report that their laboratories cut full-time equivalents over the last year, and 30 per cent expect to lose some during the next three years (Figure II). On a more positve note, 41 per cent held their own with no change in staff size, and almost half predict no further s cutbacks.

A small proportion of laboratory staffs even managed to grow. About 17 per cent of those polled hired additional FTEs in 1984, and 24 per cent hope to add more during the coming three years. The outlook is brightest for laboratorians at independent labs and non-DRG facilities. Forty-seven per cent of the independents expect to hire more people, as do 39 per cent of the laboratories not governed by DRGs.

So far, laboratories in the Midwest and the West have been hardest hit. Approximately half of them experienced a drop in staff size during 1984, compared with 30 per cent in the East and 40 per cent in the South. The Midwest respondents are especially concerned about the future, with 36 per cent predicting a continued decline in staff size. Cuts appear most likely in larger hospitals; 42 per cent of panelists from hospitals with more than 300 beds believe they will lose even more full-time equivalents, compared with 30 per cent of those working in smaller hospitals.

Attrition has claimed the lion's share of these FTEs, and was cited as a cause of cutbacks by s nearly 80 per cent of the panelists. (Figure III shows how staffing has decreased and why.) The laboratory staff at a California pediatric facility, for instance, dropped from 138 to 98 full-time equivalents over a four-year period, largely through attrition. Selective layoffs by seniority trimmed the staff size for 17 per cent of those laboratories that experienced cuts, while an equal number of panelists report a cutback in paid hours. It is encouraging, however, that only five of the surveyed facilities faced across-the-board layoffs.

Why were staffing cutbacks necessary? Simply put, testing is down, and less money is available for salaries. Fifty-six per cent of the panelists say their labs are performing fewer tests. (In labs not subject to DRGs, that figure drops to only 29 per cent.) Workload has dropped in roughly two-thirds of the laboratories in the South and Midwest, in about half the laboratories in the West, and in only a third of those in the East. Budget cuts also helped trim staffing in 55 per cent of all surveyed laboratories.

DRGs have unquestionably taken their toll. Implementing the system carved $10 million from the budget of one mid-size Minnesota hospital. Staffing was immediately cut, and the medical technology school is closing after its 49th year. At another Minnesota hospital, a nursing strike led to a 10 per cent staff reduction; thanks to prospective payment, many staff members were not called back at the end of the strike. The combination of laboratory computerization and a massive drop in state funding resulted in a 10 per cent across-the-board cut at a large Philadelphia hospital last year.

The reorganization of laboratory services triggered staff cuts in 26 per cent of the labs. This trend is strongest in the West, where 48 per cent of the panel reported recent reorganization. Some laboratories are merely revamping their structure to accommodate new outpatient or support services. Others, though, are part of the tide of hospital mergers aimed at more streamlined and competitive purchasing and administration.

Staff size did not change in at least 40 per cent of all pan lists' labs. Many of these have already experienced cutbacks for a variety of reasons; others expect to begin trimming staff in the near future. An Atlanta panelist explained that, since her mid-size hospital had previously been operating at more than 100 per cent occupancy, the onset of DRGs helped lower the census and bring workload in line with staffing.

Despite rampant DRG hardships, some laboratory staffs actually grew in the last year--17 per cent of those surveyed, in fact. The most likely place for staff growth was in independent labs; 37 per cent of these panelists reported a larger staff in 1985. Most of these facilities had been managing with fairly lean staffs, and augmented them in response to bigger workloads.

As we mentioned, almost onethird of all panelists are braced for further staff reductions. Budget s cuts pose the main threat, cited by 62 per cent of this group. Those working in large labs under the DRG system are the most pessimistic about future cutbacks.

Automation is expected to eliminate staff positions in 51 per cent of the labs, particularly in the South and West. In terms of actual testing, smaller volume is a greater potential problem than smaller test menus. While 46 per cent of those who anticipate a staff cut worry about lower inpatient testing, only 16 per cent believe a smaller in-house menu will influence staffing (Figure IV).

Some members of the panel look for growth instead of cutbacks in the near future. About a quarter of them expect their laboratories to add FTEs in the next s few years, mostly on thebasis of a spurt in outpatient testing anticipated by 72 per cent of this group. Sixty-two per cent of them expect to need more staff members to handle a larger in-house test menu.

Those who believe staff levels have stabilized tend to echo one Eastern lab director, who commented, "We're as lean as we can possibly get--unless the hospital closes down." An Ohio lab manager spoke for many panelists when he said, "We've reduced hours in a department where there never was any fat. We need more business, not just cuts."

Many respondents report that business is picking up as hospitals begin to challenge reference labs for outpatient test business, especially in the nursing home market. Sue Osier, hematology supervisor at Atlanta's Northside Hospital, reported that their 100 FTEs are extremely busy. "We're in a high-growth area; we serve as a regional coagulation referral facility; we've opened an outpatient oncology treatment program; and we're adding 100 beds."

If staffing has been in flux at the bench, it is rock-solid in the managerial ranks, regardless of virtually all demographic factors. Roughly 75 per cent of the panelists report no change in the size of their management staff in the past and expect none in the future. Twelve per cent of the labs lost managerial FTEs during 1984; 12 per cent gained them. During the next three years, 13 per cent expect to see their management staff grow, and an equal number expect it to shrink.

Why has the management tier remained so stable? Often, supervisors are filling in at the bench for departed technologists and doing administrative chores after hours. The organizational structure of one West Virginia lab, a panelist explained, makes it impossible to cut supervisory slots. "The only way we could do it would be to consolidate the sections," she said, adding that this might be considered if the census and FTE totals continue to slide.

A minority of labs have cut management staff, mostly through retirement and centralization. A single supervisor now s oversees both the day and afternoon shifts at a small Mississippi hospital, and a New Mexico hospital lab shares a chemistry supervisor with a smaller hospital managed by the same corporation.

Despite a decreasing bench staff, some laboratories are creating managerial slots to prepare for future expansion, as at Memorial Medical Center in Jacksonville, Fla. "We lost FTEs during 1984, but added an administrative position specifically to handle marketing for the lab's new outpatient testing, andrology, and in vitro fertilizztion programs,c explained Sharon Feldkamp, assistant administrative director of laboratory services.

* Qualifications. Of course, there is more to the economics of staffing than the number of people on the payroll. Some observers have predicted a change in the type of staff as well--specifically, a move to less highly educated, less costly personnel. In the lab, that usually translates into more technicians and fewer technologists. Had our panel seen signs of this trend?

At this point, more than half said no (Figure V). Almost 60 per cent foresee no change in the ratio of MTs to MLTs. A sizable 29 per cent, however, predict that the ranks of MLTs will swell. Geographically, MLTs will be most welcome in the South, Midwest, and West. Technician jobs will be hardest to find in the East; 23 per cent of the panelists in this region expect the proportion of MLTs to drop.

Many panelists voiced concern over the trade-off of an MLT's lower salary against the higher cost of an MT's expertise. The consensus was that we will probably see more MLTs at the bench for simple or highly automated procedures, with technologist talent reserved for supervision and specialties such as microbiology, immunology, cytology, and virology. A California panelist noted that his laboratory has been enlarging its technician ranks for the last four years. "Entry-level technologists are paid $11 per hour, compared with $5.50 for technicians," he said. "It simply doesn't make sense to hire MTs for routine, automated laboratory work."

Dissenters point out that certain areas demand the problem-solving and troubleshooting capabilities of a degreed technologist. Many hospitals still automatically hire graduates from their on-site MT training programs, tapping a ready pool of candidates who require little extra orientation.

Medical technologists offer increased versatility that equals greater productivity, according to a Texas lab manager. "MTs can do an MLT's work if necessary, but MLTs cannot handle all of an MT's responsibilities," he explained. A number of panelists from small or rural hospitals commented that a technologist's expertise becomes crucial when working alone or handling call. In one VA medical center, a supervisor reported, MLTs have been upgraded to technologist status following 36 hours of in-service medical technology training.

Across the country, it's becoming harder to justify paying a medical technologist's wages for what may essentially have become sophisticated button-pushing. An Atlanta supervisor said that her lab's 100 per cent MT staff is a thing of the past. "We're in the midst of a major expansion and will be bringing in MLTs at the bench. We've had more than enough chiefs for a long time--right now we need Indians!"

Panelists foresee a major problem in finding enough qualified technicians to meet the rising demand. Some MLT schools are closing along with their MT counterparts, and technicians are reportedly in short supply in many communities. A hematology supervisor from Wisconsin reported that her hospital is reclassifying MT positions as they are vacated; however, few MLTs have been available to fill the newly designated slots. The lab's olution so far: Hire MTs at the MLT pay rate.

Some laboratories have gone a step further and opted for on-the-job training. A Tulsa panelist says that phlebotomists are learning to perform automated chemistry and hematology procedures in a laboratory that currently has 135 FTEs, most of them technologists. "The MTs felt threatened at first but now realize that these laboratory assistant positions can help us prevent layoffs," she explained. An Ohio laboratory manager predicts that, as job functions begin to mesh, laboratory assistants will someday handle most routine procedures.

Glen McIver, laboratory director at Bedford (Va.) County Memorial Hospital, is one of several panelists who has grown weary of all this emphasis on titles and training. "I judge techs by their competence, technical ability, and how they accept responsibility--not on what degree they hold," he said. "I've seen too many unsatisfactory MTs and too many superb MLTs to categorize anyone on education alone. Both are treated equally here. Annual merit raises are based strictly on performance."

* Scheduling. The impact of current changes goes beyond the size and makeup of laboratory staffs. It has also influenced when and how these people work. Although the standard eight-hour shift remains the norm in 74 per cent of the laboratories surveyed, the remainder have adopted various alternative scheduling methods to achieve optimum efficiency.

Flexibility is crucial these days, our panel reports. Technologists rotate from section to section in more than 70 per cent of their laboratories, most often on the second and third shifts. Rotation is most likely in hospitals with fewer than 300 beds; technologists work in more than one section at 84 per cent of these facilities, compared with only half of the larger hospitals. In 79 per cent of the independent labs, rotations are also the norm.

Technologists are now expected to have broad technical expertise, or to develop it. To see that they do, 48 per cent of the panelists' laboratories offer a formal cross-training program. This finding is consistent with the panel's outlook on training; 54 per cent predict that future laboratory staffs will require more generalists, while 51 per cent expect to see fewer specialists.

This doesn't mean that the medical technology field no longer has any room for specialists. Microbiology is one area that continues to require specialized knowledge; another is the blood bank, according to Susan Stewart, blood bank supervisor at Detroit's Harper Hospital. "Specialists and non-rotaters will continue to be in demand because of the blood bank's specialized techniques, and the need for rapid and accurate decision making," she predicted.

DRGs have also altered the traditional pattern of hospital shifts. With the growing trend to admit patients later in the day, the standard 7-to-3 workday is fast becoming obsolete. Although most laboratories still follow the usual eight-hour schedule, one-fourth of those surveyed have adopted alternative shifts. Eastern laboratories adhere most rigidly to the traditional schedule, with 82 per cent of these facilities using standard shifts; in the West, by contrast, 42 per cent of the laboratories have switched to more flexible scheduling.

Ten-hour shifts are by far the most popular option. Among panelists using nontraditional schedules, nearly two-thirds report that at least a few technologists work four 10-hour days each week. Other technologists work shifts that last for 9-1/2, 12, or even 16 hours.

In other labs, technologists follow a seven-on, seven-off schedule--seven 10-hour days followed by seven days off. The microbiology supervisor at a California lab with 6.6 FTEs reports that, as part of the weekly schedule, each technologist works eight hours, takes call for the next 12 hours, and then works a second eight-hour shift. Technologists who are called in receive OT.

Even laboratories retaining eight-hour shifts have begun to stagger the starting times. "Split shifting is a must for our blood center, because the workload depends on when we receive blood from the drawing sites," comments the director of special services for a regional Red Cross center.

Weekend staffing has become especially creative. Some laboratories have adopte dthe Baylor plan, which offers employees full pay for working less than a 40-hour week. Often, the variance in hours worked versus hours paid depends on the level of stress. Technologists in the Stat lab, for s example, might work fewer hours than those performing routine testing. In a large Florida laboratory, two 12-hour weekend shifts equal 36 weekday hours; in one North Carolina laboratory, technologists work three 12-hour shifts, but are paid for the full 40-hour week.

Other laboratories handle weekend coverage by scheduling two 16-hour shifts. In one small Southern laboratory with three FTEs, technologists work abbreviated shifts and then take call for the remainder of the eight-hour tour. "This allows our small staff to keep the lab open from 5 p.m. until midnight," the laboratory supervisor noted.

Have these marathon shifts damaged efficiency or morale? Quite the contrary, it seems. "Some of our happiest techs are those working the 24-hour weekend tour," noted the Florida panelist whose lab follows the Baylor plan. "There's very little turnover, and we have a waiting list for those hours; it's an ideal schedule for graduate students."

Of course, some staffers, such as computer operators, do get tired by the end of a 10-hour day, and a Western laboratory manager notes that, even with 106 full-time equivalents, the logistics of providing seven-day coverage can be a major challenge with much of the staff on a four-day schedule.

As flexible staffing becomes the rule, it's no surprise to find that at least 88 per cent of the panel--90 per cent of all hospital labs and 76 per cent of the independents--the part-timers (Figure VI). Exactly half expect to hire additional part-time help in the next three years, and only 7 per cent expect the number of part-timers to decline. Among labs not now using part-time help, a third will probably do so in the future.

Panelists cite several reasons for the projected increase in part-time laboratorians. Administrators find part-timers especially attractive because they allow comparable staffing with a major savings i benefits; many full-time slots are now likely to be reclassified as part-time positions. Many labs count on part-timers to compensate for recently departed full-timers, and to provide the staffing flexibility needed for fluctuating patient census and workload.

Overtime is another scheduling ploy to adjust staffing to workload--one used by 86 per cent of panelists' labs (Figure VII). This figure climbs to 91 per cent in hospitals with more than 300 beds. The prevalence of overtime s varies somewhat depending on staff level. Technologists receive overtime pay in 86 per cent of the surveyed laboratories; technicians, in 77 per cent; and the clerical staff, in 64 per cent. A few hospitals grant overtime to supervisors, while several approve occasional overtime for phlebotomists and lab aides.

Cost pressures promise to turn overtime into a luxury many laboratories can't afford. Forty-four per cent of the panelists expect total overtime hours to decrease over the next three years, while 42 per cent anticipate no change. Only 14 per cent of the panelists expect an increase in overtime. Economically, hiring part-time help tends to be a better deal--even after factoring in the cost of additional employee benefits.

One innovative solution to the squeeze on hospital payrolls proved strikingly popular. Over 40 per cent of the surveyed labs allow staff members to take a voluntary cut in hours during slack periods. Call it voluntary vacation time, budget hours, release time, no-pay vacations, or excused absence time, the end result is the s same: When the workload dips, some staff members volunteer to go off the clock, making it economically feasible for the laboratory to operate at full staff during peak hours.

Nearly 60 per cent of the panelists whose labs have tried this option say that the program works well. Twelve per cent add the qualifier that this approach is valid as long as it's truly volunatry; others point out that an occasional unpaid hour is much better than full-scale layoffs or an across-the-board pay cut. Indeed, the lab manager at a large Philadelphia medical center would very much like to implement such a plan, but reports that the union has vetoed this compromise measure in favor of layoffs by seniority. Only 5 per cent of the panelists have found that volunatry time off has harmed morale, although several note that there are few slack periods and even fewer volunteers.

An unpaid-hours program, if administered fairly, can produce excellent results. In many laboratories, this approach has decreased staff size by several FTEs without a single layoff. Sharon Feldkamp of Jacksonville, Fla., reports that the plan helped the laboratory comply with a 10 per cent across-the-board cutback in hours, to the current level of 85 FTEs. "when the hospital made the announcement, we put it to a lab vote,c she said, "and the overwhelming majority opted for the reduction in hours."

Several labs have developed their own variations of time off without pay. A Nebraska pediatric hospital pays volunteers for half of the remaining work day, while a Minnesota medical center offers full benefits for a 32-hour part-time schedule.

Problems can arise, especially when management makes the program mandatory. A Pennsylvania laboratory director recalled that her hospital lost ime and money training replacements after the patient census eventually began to rise again. Other laboratories have had to call in part-timers when the workoad unexpectedly peaked, thus saving very little money. A New York chemistry s director summed up what many technologists fear about the plan. "We were told that our financial position was very tenuous and were put on mandatory cut time, losing one full day per pay period,c she recounted. "At the end of the fiscal year, the hospital actually had a surplus of funds, so the unsalaried employees lost money unnecessarily."

Many panelists would only support unpaid hours if comparable efforts were made to reduce waste in top management. Several are skeptical about actual savings if full-time benefits are continued, and most emphaisze that benefits must be protected. Some respondents fear that this temporary measure will become a permanent policy, or dismiss it as a quick fix for a long-term problem.

Clair Jaberg, labortory manager at Children's Hospital Medical Center in Akron, is concerned that non-patient-related responsibilities will suffer if technologists leave whenever the bench is clear. "A well-managed, lean staff uses slack time to review procedures, perform quality control, and take care of the other functions necessary for accreditation that are generally secondary to patient care," he said.

Amid all these changes, our panel found room for optimism. Some report that their labs have diversified, offering a variety of new services--from in vitro fertilization to industrial toxicity reference testing--that might not have gained administrative support without the new emphasis on the bottom line.

Part II of this special report looks at where the medical technology profession is headed, and examines what turns the panelists expect their careers to take next.
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Title Annotation:part 1
Author:Hallam, Kris
Publication:Medical Laboratory Observer
Date:Aug 1, 1985
Previous Article:Are clinical labs next in the deregulation revolution?
Next Article:Laboratory careers: mixed signals for the future.

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