Improving lab productivity: the search for strategies.
The preceding article pointed out that half our panelists reported 1983 productivity gains. This year, as more hospitals come on line for prospective payment, an even greater percentage of these managers and supervisors anticipate running more productive operations. As Figure I shows, 64 per cent of the survey respondents expect higher output in 1984; a quarter expect no change; and only 11 per cent project that productivity will decline.
Some of the improvements will be by long-planned design, some by urgent fiscal necessity as laboratory management faces administrative pressure to cut labor and other costs as deeply as possible. "We're counting on improved automation and greater instrument reliability," a Midwest pathologist reports. "Our productivity will probably increase due to a hiring freeze coupled with an increase in lab requests," one chemistry department head says. "Somehow, all the work gets done."
"Budgets are being cut or frozen while workload increases," a Pennsylvania microbiology chief says. "If we can't hire additional people, productivity must increase. The alternative is lower quality with longer turnaround time, poorer quality reagents, or fewer services."
The manager of a Massachusetts laboratory puts it simply: "Fewer people will do more tests!"
Our survey turned up revealing staffing and workload trends over the last three years. We asked panelists to chart their labs' average change in the number of fulltime employees and in-house tests performed annually (Figure II). The rate of staff growth fell from 4.5 per cent in 1981 to less than 2 per cent in 1982 and 1983. Meanwhile, annual test volume grew by 9.4, 10, and 8 percent during the three-year period.
Clearly, more work is being done by proportionately fewer people. Of course, these figures don't mean technologists are universally overworked. High-throughput automated instruments are lending a hand. In fact a number of laboratories are working below maximum staff capacity due to insufficient test volume.
Nevertheless, overall workload seems destined to outpace staff growth for the immediate future. Economy and efficiency will be watchwords for maintaining professionalism and quality service.
In many labs, high technology will come to the rescue. Exactly 64 per cent of our respondents--the same proportion projecting improved productivity this year--report that their laboratories plan to add more automated instruments to help reach productivity goals. That figure is especially impressive in light of prospective payment and its anticipated bite into capital equipment budgets.
In the race to automate, one laboratory department leads the rest: clinical chemistry. Fully 79 per cent of the panelists who plan to add automated equipment will do so there. Hematology and microbiology tie for a distant second, with 47 per cent of these surveyed planning to add automation in those department. Last comes immunology, slated for automation by 16.5 per cent, and the blood bank, cited by only 6 per cent.
Not surprisingly, automation also headed the list of respondents' past productivity tactics (Figure III). Automated instrument purchases figured in the efforts of 70 per cent of all surveyed laboratories. The two other most popular measures were schedule changes, cited by 60 per cent, and specimen batching, by 45 per cent.
Meanwhile, a third of the panelists say they have tried to improve inventory control, cut staff train employees to be more productive, or increase test volume by reducing reforence testing. Almost as many have coached employees, boosted volume through bigger test menus or outpatient marketing, and dropped time-consuming tests from the menu.
Several other items on this strategy list drew a strong response. About a quarter of the panelists have made efforts to cut instrument downtime and Stat abuse, improve test ordering patterns, or decrease total work hours. More than a fifth tried to spruce up the work environment, and almost 18 per cent raised employee standards of performance.
One item here is notable for its low response rate: Only 8 per cent of the panelists said they had hired less educated staff members, despite a recent spate of predictions the DRGs and tight payrolls would prompt many lab managers to do so. We'll examine the issue in detail later.
How well are these productivity measures working? Results are good, according to 40 per cent of the panel, and fair according to another 57 per cent. Only 3 per cent labeled the outcome of their efforts as poor.
We also asked panelists about the impact on quality of service. More good news: 42 per cent say it has improved slightly, and 13 per cent claim a significant improvement. Productivity measures have left quality unaffected for 40 per cent, and lowered it slightly in a mere 5 per cent of all laboratories. Only one respondent reported that such efforts had cut quality significantly.
Test charges also showed little impact. While productivity efforts increased charges in 18 per cent of the laboratories, they caused no change in 75 per cent, and actually reduced charges in 7 per cent.
So far, then, the drive for increased productivity doesn't appear to be hurting laboratories too badly. But how much is it helping? To find out, we asked the panel to name their most and least successful productivity strategies. The results are summed up in Figure IV.
Once again, automation tops the list of success stories, cited by 27 per cent of the panel, followed by schedule changes; named by 19 per cent.
Often these two approaches go hand in hard. Jane Sheridan, lao supervisor at 110-bed Valley Memorial Hospital in Livermore, Calif., says: "Our biggest change in the past year and a half was to drastically increase automation, bring chemistry panels in-house, and make the necessary staffing changes. We needed to adjust staffing on a weekly and even a daily basic according to workload fluctuations, so we now have several technologists working on an on-call, per diem basis."
A scheduling arrangement called sem-flextime works well for the four-person staff it Cornell University's Gannett Health Center in Ithaca, N.Y., a busy seven-bed student clinic. "During peak hours, we all stay here," laboratory supervisor Kathleen Crown says, "but if workload is low, we encourage two-hour lunches to cut down on paid work hours." Crown believes in giving a lot of independence to her team. "When people are producing as much as these are, it's important that they help set up their own work systems."
A reduction in paid hours through staff cuts was the most successful move for the laboratory at 125-bed Martian Medical Center in Santa Maria, Calif., at least in dollars and cents. "In terms of morale," chemistry department head Deborah Kinnick says, "staff cuts were also the least effective. One of the best approaches to higher lab productivity is skillful personnel management, with particular emphasis on employee morale." The rest of Kinnick's thoughtful comments appear in the box on page 52.
Less than 10 per cent of the panelists voted for improving morale, encouraging the staff, or counseling as their top productivtiy tactic, but those who did are true believers. "If technologists are actively involved, and sense that we appreciate their efforts, productivity remains high," says Kenneth Moore, manager of ancillary services at Melbourne Internal Medicine Associates, a group practice clinic of 15 internists in Melbourne, Fla. "We try to get input right at the bench level, through roundtable discussions on upcoming projects. They have to live with our decisions, so we try to work something out together. In our experience, they hold up their end of the bargain." Moore encourages section chiefs to pick departmental goals and objectives, and to extend the goal-setting process to individual staff members.
Quality circles, the participatory management technique popularized by Japanese industry, helped the laboratories of Normandy Osteopathic Hospitals, a 350-bed system in St. Louis. Quality control coordinator Gary Stocker taught himself the basics, and set up circle groups of technical and clerical staffs at both hospitals. Leaders from each group took a two-day training course, and put the brainstorming process in motion.
"Once our people had some input into the formal line of authority," Stocker recounts, "it spurred their interest to start projects that we couldn't have begged or forced them to do eight months ago." One recent group achievement was a poster campaign for cost containment awareness.
For 10 per cent of the surveyed labs, the best response to productivity pressures was to cross-train employees or hire more educated staff. Cross-training technologist between the blood bank and chemistry departments was a boon to the laboratory at St. Joseph Mercy Hospital in Ann Arbor, Mich. "They usuall work two to three days a week in one section, and spend the rest of the week in the other radiochemistry supervisor Julie Ann Brown says. "It makes people more versatile, reduces the boredom of staying in one section, and helps us avoid hiring new people since we can make better use of those we have."
Brown believes that hiring less educated employees, a much-pre dicted trend is false economy.
A mannger can end up was lot of time explaining to inacequately trained people why the have to balance the centrifuge or wash their hands after handling suspected hepatitis specimen."
The laboratory at Rush-Presbyterian-St. Luke's Medical Center, a 1,200-bed Chicago institution, discovered that less educated labor is not necessarily cheaper in the long run, according to lab manager Glenn Detweiler. "Hiring more highly educated staff was our best productivity move," Detweiler Says. "We found they needed less orientation, were more flexible, and showed more initiative in using their time effectively. Certainly, many jobs can be filled by less qualified people, but in the long run you lose a lot of cross-training potential."
Some laboratories do feel a growing need to justify the salaries of certified medical technologists for highly automated jobs. "Except for our phlebotomy team of MLTs and CLAS, we've never had anything other than certified MTs with baccalaureates," says Bernadine Goyette, program director for the medical technology school at 30-bed Bethesda Lutheran Medical Center in St. Paul, Minn. "But administrators know that you don't need a four-year degree to operate many of the micorprocessor-controlled instruments. We can justify hiring MTs as department heads or senior assistants, but what about the rest?" So far, Goyette's lab has trimmed the payroll trhough voluntary days off without pay and unfilled vacancies.
A less educated tier of staff can increase lab efficiency, however. That's the case at 79-bed Arroyo Grande Community Hospital in Arroyo Grande, Calif. "Our lab aides perform all the demographic date entry, run the automated analyzers, draw blood, and do billing. They're indispensable," lab manager Robert Grayson say. "Technologist duties are strictly limited to clinical testing." Grayson notes that California law forbids unlicensed personnel to perform any but the most basic lab tasks requiring little or no interpretive skill.
Aside from these basic trends, panelists described diverse alternative routes to enhanced productivity, including boosts in volume. Marketing for outpatient testing business, combined with careful assessment of personnel and equipment needs, has enabled the laboratory of 238-bed Pleasant Valley Hospital in Point Pleasant, W.Va., to weather a drop in inpatient testing due to a depressed local economy. "With our census down," administrative technologist Joseph Dressler says, "we decided we'd better look at some other options."
Dressler conducted a feasibility survey to find out what the medical staff and community physicians wanted in a reference lab. The answers were quality service, rapid turnaround time, and competitive pricing. Outpatient volume has already picked up since the laboratory began local couner service and Dressler expects it to increase eventually by 25 per cent or more. Most important, his facility has avoided the layoffs that have hit many area hosiptals and labs.
A few respondents labs are producing more by adding staff selectively. At the Bay Pines Ha, Veterans Administration Medical Center, staff cytologist Laura Akens reports that operations were streamlined and downtime was reduced following reassignment of a hospital bio-medical technician to full-time service in the laboratory. Before, red tape made for slow and costly lab repars at this 1,088-bed institution. Now, one person supervises all maintenance records and performs prompt troubleshooting.
Among the panelists' least successfuly tacties were attempts to curb Stat abuse. At 259-bed Leonard Morse Hospital in Natick, Mass., the lab added a yellow Stat slip to the requisition process in an effort to track abusers. "It resulted in massive paperwork," technical supervisor Catherine Brown recalls. "All we discovered was that the emergency room labeled everything Stat, and that's Common everywhere."
After two years of use, the Stat slip is still largely ineffective, despite regular efforts to educate the nursing and medical staffs. This year, Brown says, the lab is relying on a new computer system for more accurate audits.
At other institutions, disappointing efforts to improve productivity ranged from mismanaged marketing efforts to poorly planned rescheduling. No option is foolproof, not even automation. At Pineville Community Hospital, a 155-bed rural facility in remote southeastern Kentucky, microbiology supervisor Gary Cornelius reports that the lab had trouble getting adequate training and service for automated chemistry instruments and winning staff acceptance for new methodologies. "Our best solution was to have people follow through and document problems in a trouble-shooting record kept with the instrument," Cornelius says.
David Risley, chief technologist at Pathologists Associated, a reference lab in Muncie, Ind., found computerized data management a successful measure, but one that was challenging to implement. "The staff's fear of technology is hard to overcome," Risley says. Within a couple of years, we went from very manual procedures to a lot of automation, capped off by installation of a lab computer. Many people felt their jobs were threatened, and it took some counseling to convince them they were still vital."
In the long run, almost half the panelists believe that automation will provide the most promising approach to increased lab productivity (Figure V). A much smaller proportion look to solutions like physician education, computerized data, improved scheduling, and simply better management to fulfill their goals.
As budgets tighten under DRG constraints, it seems likely that laboratorians around the country will try all these methods, and more, to give health care consumers the most for their money.
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|Title Annotation:||special report - part 2|
|Publication:||Medical Laboratory Observer|
|Date:||Mar 1, 1984|
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