Low and inside: reducing staff turnover

One path shows what the progression would look like if an employee returned to school to advance from MLT to MLS, for example. Another path would enable a tech to become a technical specialist, a quality specialist, or some other role. In some cases, laboratory workers have become account reps within the outreach program. One laboratorian became a billing manager, another a business analyst. Some have become project managers.

For those who want to stay in their current job, there are other discussions to be had. “What do you want to learn more about?” Rocheford asks. “Do you want to develop project management or other skills?”

And regardless of the answer, Rocheford wants to know, “How can we help you get there?”

That creates an interesting dilemma, however. When staff outgrow a job, that creates more turnover.

True, says Rocheford. But from her perspective, not all turnover is created equal.

Allina has worked mightily to foster the one-lab, many-sites mentality. Until recently, every lab looked out primarily for itself. “People did not want to give up their people to other sites,” Rocheford says, because it meant they’d have to fill yet another position. (She notes that turnover refers to individuals who leave Allina altogether; those who transfer within Allina are not included in the numbers.)

Now that staff are encouraged to move around the system and gain new experiences—try a clinic lab, try a regional or metro hospital, try the central lab—Rocheford and her colleagues have also had to send a fresh message to leadership: Promoting staff growth may be hard, but it’s the right thing to do. “And just as we encourage employees to go to another site, we’re going to encourage people to come to your site.” The added bonus: “We’re developing stronger techs because of this.”

The commitment to growth runs deep. Dr. Anthony notes that when someone applies for another job and doesn’t get it, it’s still seen as positive. “You’re attempting to grow, you’re visible, and you’re putting yourself out there.” She’s seen staff interview for several positions and calls it a welcome sign of eagerness. “They don’t seem deflated—I see them continue to look.”

They’re helped along by supervisors who abet growth, says Rocheford. “Other leaders don’t look down on them when they learn their staff member has applied for another job.”

“Turnover of some sort is actually good,” she adds. “It’s not great to stay in one job forever, as oftentimes it can inhibit personal growth.”

Tony Bull, executive director, AdventHealth Lab, Orlando, Fla., agrees. He oversees the outreach department, with its approximately 164 employees. Many of his billing employees eventually transfer to other positions, including in the lab itself. “We don’t necessarily see that as a loss,” he says, even though it means having to find replacements. “Of course we’d like to keep them, but we see it as a benefit to the system when we can keep using their talents.”

For all the positive culture changes, one area of employee engagement remains tricky, says Dr. Anthony. Within the laboratory profession, staff are encouraged to be visible—to physicians, nurses, patients. And staff themselves enjoy that aspect of their job; it makes them feel engaged.

Some may ask if labs can afford this. “We can’t really have people stepping away from the bench, because it’s so time-consuming. We don’t have as many people go on bone marrows, because that decreases productivity,” says Dr. Anthony.

But can they afford not to? “I know the clinicians value the calls, and it makes them value the lab,” she says. So do lab staff. “People just relish it—it makes them feel like they want to come to work. If they see a patient longitudinally, it makes a big difference in their engagement. They want to be part of a health care team.”

“There’s two conflicting messages,” Dr. Anthony says. Do you err on the side of efficiency? Or engagement? And are they really two separate things?

By now, most organizations realize that it’s inefficient to have high turnover, says Bull. The dime-a-dozen approach to hiring entry-level employees has finally found its proper place on the scrap heap of hiring attitudes. “The phlebotomists and couriers are the face of our laboratory. And we tell them that,” Bull says.

He also notes that they’ve improved communication when hiring phlebotomists, adding a second interview with Bull or with an assistant director. Turnover has held steady at 12 percent for about a year, and he suspects the improved selection process may be one of the reasons.

Yet other struggles persist. NorDx’s Schofield says that despite the perpetually high turnover in jobs like phlebotomy, he’s never had the attitude that it’s acceptable. “But no one pays very well for their services. They’re not valued the way med techs are, and med techs aren’t valued the way nurses are.”

He recalls much more equity between RNs and med techs decades ago, but “nurses have left the laboratory pretty much in the dust.” The lab suffers from invisibility (as Dr. Anthony notes), including minimal bedside interactions. Higher visibility translates into higher perceived value, and thus salaries. “A nurse treating a patient can generate room charges and ancillary services of thousands of dollars a day,” Schofield says. “The med techs generate lab results, which the hospitals bill out at thousands of dollars each. But that’s not how they’re compensated.”

Schofield runs through a long list of ongoing efforts NorDx has made to tackle turnover. They help chart career advancements for employees. If a phlebotomist wants to work as a lab assistant or a histotech or in specimen management, “We pay you $13 an hour to train you. If you want to get a bachelor’s degree, we’ll train you at a higher level—we will support you all the ways we possibly can.” For those who have undergraduate degrees and want to move into management and leadership, “We’ll help them get their MBAs. We’ve graduated 20 MBAs. We help people get their Lean experience.” Job openings are widely posted; career advancements are widely shared with colleagues. NorDx also hosts career fairs and does hiring blitzes on social media and radio, Schofield says.

He sees no slowdown in these efforts. Competition will only increase. “Those who worked in labs 15, 20 years ago didn’t have the same opportunities they do today,” he says. Why become a phlebotomist if you can go into video game design, he asks.

Things aren’t any better in the middle. When a med tech quits, it can take Schofield anywhere from a year to a year and a half to hire someone new, especially for sites that are in more remote parts of the state.

Automation might offer a partial solution. And he’s looking at the feasibility of hiring foreign medical graduates, which has been successful in other parts of the country, including Southern California, he says.

Beyond that, there may be a need to look at a change in service models. He needs to staff his hospitals 24 hours a day; if he reduces the second and third shifts to one person, to support the ED, the rest of the lab work will need to be sent to the core lab, which may be 100 miles distant. “This can be done, but it’s a hard argument.”

Like Rocheford, Schofield has found that while departing employees frequently cite poor pay during exit interviews, he’ll find a different issue when he digs deeper, including a bad boss or bad management.

Scheduling is the other big reason people leave, and Schofield suspects generational shifts in attitude might contribute. He characterizes younger employees as highly independent and uncomfortable with structured environments and management. That doesn’t always mesh well with the realities of patient care, he says. Although the lab can accommodate employees who regularly need schedules that fit schooling needs, for example, it’s not realistic to provide schedules that vary greatly on a day-by-day basis.

“If you don’t want to work weekends, and you don’t want to work the second shift, maybe this isn’t the place for you,” he adds. It’s helped to conduct job shadowing before the start of training programs, he says. Candidates spend one day at the hospital and one day at the core lab to get a fuller sense of what the job entails. Afterward, many remain interested in the work and can move forward with no surprises. “And there are people who say, ‘I don’t want to do this—it’s not what I thought it was,’ and then we all part as friends,” Schofield says.

Communication is the enemy of surprise, which may be one reason employees at AdventHealth Lab have asked for more of it. “That’s been a longtime complaint from employees, that they’re not getting good communication,” says Bull. In fact, he heard this frequently when employees were headed out the door, during exit interviews.

Those pleas appear to have been heard. “There’s been conscious effort on our part to have a lot more communication, to have one-on-one meetings with every team member,” he says. They’ve also added a structured monthly meeting to improve communication. He credits the efforts with reducing his lab’s turnover rates.

Handled poorly, communication can be scattershot, Bull says, and it can vary from manager to manager, based on their interpretations and management style. The monthly meetings can smooth out those individual quirks. “We’re able to make sure that the information does get to everyone,” he says.

Oftentimes the meetings will cover mission and strategies for patient care. “We ask for input from employees,” Bull says. “We talk about areas where they think we can improve. We talk about wins and things that are going well. I’ve been surprised by the depth of the discussion. In some cases, we talk about ethical dilemmas and how to handle them.”

Employees want to be heard, Bull says. Just as important, “We need to make sure we follow through on their concerns.” Management inaction can lead to employee action—i.e. turnover.

Bull reiterates the notion of changing the culture. It wasn’t enough to say employees could bring up problems or concerns without fear of punishment. “You have to prove it,” he says. “You almost have to wait for the opportunities to show that you mean what you said, that there won’t be retribution.” He says he makes a point of complimenting employees for coming forward, both publicly and privately.

He recalls the day when he realized the message was indeed getting through. Colleagues were celebrating the accomplishments of a manager who had reached a benchmark. (In addition to communication, employees’ other most frequent complaints have been lack of recognition and lack of advancement opportunities, Bull says.) The manager acknowledged that deadlines were indeed being met—but that they were also starting to see higher error rates. “He just wanted everyone to be aware of it, and that he’d appreciate help,” Bull says. “That’s the kind of culture and dialogue we want.”

Turnover, as it turns out, might be a marker of ebb and flow, rather than loss and gain. Ultimately, say Bull and others, stasis might be unhealthy in employees as well as patients. The tradeoff between engagement (or compassion, Bull’s preferred word) and efficiency may be a false dichotomy.

A positive environment for employees, by any of the aforementioned measures, “means we’re going to do a better job all around,” says Bull, though he concedes it’s hard to measure the impact of employee engagement. Nevertheless, he’s convinced it’s real. “There are payoffs with patient satisfaction and the service level. I think we have good employee accountability. I think we get more employee ownership, which I hope helps us to reduce errors and improves patient care.”

“I don’t mean for this to sound like it’s perfect,” Bull hastens to add. “We struggle with turnover and work through it. But I think we’re on the right track.”

It’s really quite simple, Dr. Novis suggests: Treat employees like the humans they are. “Forget about paying for their CME or even giving them a career path,” he says. “That’s what you do when you get the culture right. You don’t just do it in a vacuum.” It’s not a matter of tactics, Dr. Novis emphasizes, though those have their place. Look at the bigger picture, he says. Who wants to stay in a job, let alone follow a career path, that’s mired in a crummy culture? 

Karen Titus is CAP TODAY contributing editor and co-managing editor.