Sherrie Rice
June 2023—The labor shortage may ease now and then for some laboratories in some areas, but the general outlook is that it will stick around for a while—if not forever.
“We have a highly trained workforce, and so they don’t just grow on trees,” said Christina Kong, MD, professor of pathology at Stanford University, in a CAP22 session on how to use creative approaches in the face of the shortage. For Dr. Kong and Stanford colleague and co-speaker Jennifer Fralick, executive director of anatomic and clinical pathology laboratories, it’s about changing the way the laboratories work. As Fralick put it, “They’re strategies to stretch or refocus the staff.”
One example at Stanford was the understaffed point-of-care testing department, where “we had the wrong staff doing the wrong jobs,” Fralick said. “We had a primarily CLS-staffed point-of-care department doing administrative work.” The solution was to reorganize such that the clinical laboratory scientists were relieved of the administrative tasks and moved to technical work only—“the work they studied for and that they’re licensed for,” Fralick noted.
Histotechnology was suffering the biggest shortfall, one for which “we were begging, borrowing, and stealing,” Fralick said. So they did a service line growth assessment, she said, to figure out how best to support it. “We looked at the oncology plan, at the surgical strategies, because they impact our histology staffing,” and they reassessed their staffing plans by examining volumes, safety, and regulations.
They had to account for digital pathology processes, too, because “it’s not seamless” or easy, Fralick said. “There is a lot of maintenance on the scanners, for example.” Now, laboratory technicians are key to their digital pathology workflow. “They are the ones doing the scanning and the ones maintaining the scanners,” and they’re doing quality assurance. “It’s been a blessing to have this position,” she said, “because it has offloaded the need to have so many histotechnologists.” The laboratory technicians also have a path to train to become histotechnologists. “Since we don’t have a histotech school to partner with, we’re kind of doing it on our own.”
In the end, they came up with a staffing reassessment plan—a 30-page business case is how Fralick describes it—that meets today’s needs in histotechnology.
“Top-of-the-license practice” is the approach they have taken for several Stanford laboratories, not only because it’s good for morale and thus retention, Fralick said, but also because some of the staff then become easier to hire. Lab technicians, lab assistants, and surgical pathology technician positions (the latter to relieve PAs, “one of the hardest staffing issues,” she said) are easier to fill. “They require training, but you can bring someone in with a high school diploma,” and without certification.
They have shifted to medical laboratory technicians some of the clinical laboratory scientist tasks, such as temperature audits and supplies ordering.
“We’ve seen so much job satisfaction. We’ve seen people smiling, happier at work,” all while “plugging the gap” in staffing, Fralick said.
Building a small labor pool is another of the steps they have taken. The cost to bring in temp workers “is not pretty,” she said, referring not only to the cost to interview, onboard, and complete the related administrative tasks but also the training. Temporary staff “have to learn your system, your policies. In some labs, based on the complexity, it could be four to six months before that person can work on their own.” And the training takes others off the bench such that there are now two vacancies—one for which the lab hired the temp and the vacancy of the trainer.
The labor pool they’ve built is based on historical volumes of how many phlebotomists, for example, had to be pulled in as temporary and for how long and at what cost. Their extensive assessments of past use of temporary staff enabled them to say they need three phlebotomists who are always in the department and move from shift to shift. “And it gives them an opportunity to work on different tasks. That way they’re trained, they stay, they are not always married to one shift.” They can apply for a shift, but they would remain in the pool, Fralick said.
The same is done for histotechnologists and CLSs, the latter of whom can work in virology, microbiology, and chemistry. “While there’s going to be training as they go from lab to lab, it’s not significant. The core foundation is there.” The labor pool helps when there are family leaves of absence, for example, and gives the staff flexibility as well.
[dropcap]D[/dropcap]r. Kong and Fralick and others look for efficiencies, too, and one way to do that, Dr. Kong said, is to “promote a culture of psychological safety, where staff feel free to bring up different ideas or to speak up when they see a problem or something that could be done better.” They see a lot and they have a lot of ideas, she said of the staff, “so it’s important to capitalize on that.”
“As we’re looking for efficiencies, they can tell you the things that frustrate them,” that they know to be a poor use of their time or to add little. “Those are things you want to find so you can change the way things are done,” said Dr. Kong, who is vice chair for medical affairs and medical director and chief of service, Stanford Health Care.
Performance improvement projects at the institutional level, while hard to find time for, create visibility for the lab, she said, and “if done correctly, they give time back to you because you find ways to decrease waste.” If there are no institution-wide programs, she said, “you can create that type of opportunity for change within your own area.” In the Stanford laboratories, one such project empowers front-line staff to lead small improvement projects coached by lab supervisors and managers. They use an iterative process. The problem is identified; a walk-through takes place to see what’s being done and to get a full understanding of the issue; and the goal, the drivers, and potential changes are documented.
“Then it becomes iterative,” Dr. Kong explained. “You try a change and you see it fails. You try another change until you identify the one that really works. Then you go back and make sure it’s effective,” all while involving the staff. “Because then they’ll start to understand that, yes, doing the thing is stupid, but to effect change takes work and it can’t be done with the flip of a switch.” Once they’re engaged, they’re good at helping to find solutions that work for them instead of being imposed on them, she said.
One improvement project at Stanford involved the transfusion team, “to hold off on crossmatching blood until call slips are reviewed. This saved 86 FTE weeks,” Dr. Kong said, “almost two FTEs of work. And it’s amazing when you start to look at how you’re doing it because they were pulling and reshelving blood products that were not being used.” It also reduced blood wastage, she noted, because “you’re not pulling things off and decreasing that time to use.”
In immunohistochemistry, they moved from paper orders to electronic orders for special stains. They did the same for FISH and other molecular test orders, and the latter shortened the molecular test turnaround time by six days, Dr. Kong said. Instead of faxing requests that would sometimes get lost, “it was a simple change that took a long project led by a pathologist to be able to figure out what would work best.”
Look at the number of submitted blocks, she suggested. “If you can reduce that, you reduce histology work, staff time to file slides, and the time you spend to read all that glass.”
[dropcap]F[/dropcap]or recruitment and retention purposes, Stanford implemented career ladders in recent years for CLSs, histotechnologists, cytogenetic technologists, and bioinformaticians, and they aim to expand it to others, Fralick said. “Not everyone wants to advance, but for those who do, this gives them a path forward,” she said.
A governance committee consisting of medical directors, managers, and supervisors from AP and CP laboratories meets twice yearly to review the applications of employees who seek promotions. The application has multiple elements encompassing people, quality, safety, service, operations, and improvement, “with quality and improvement weighted higher than the other areas,” Fralick said, and a letter of recommendation from the employee’s supervisor is required.
“There’s a long list of criteria and they can say, I’ve done this and this is when I did it, and they provide supporting documentation” for the committee. “We say, ‘This person needs to get promoted,’ or maybe we go back and request additional documentation. Sometimes we say, ‘No, you’re not ready. Let’s hold you until next time,’ so there are rejections but it’s rare.”
As a CLS, an employee can go from staff to senior to reference technologist, for financial gain and to take on more advanced tasks such as test validation and development. For all staff, whether they prefer to stay where they are or apply for a promotion, “we try to keep the work exciting, so everyone at every level will stay engaged,” Fralick said.
To retain pathologists, Stanford implemented time-limited director roles, Dr. Kong said, “because especially in academic institutions you see people leave because they want to be a director of their service but they don’t see opportunities for it at their own institution.” A director at Stanford who is in the role for five years can be renewed for another five, and during those additional five years would identify a successor and prepare them to take over. “It creates opportunities for people to move into those positions so they don’t have to go to another institution to advance their career,” Dr. Kong said, adding, “It also means better transitions.”
The outgoing director doesn’t “go off into the sunset,” she said, noting there are other roles they can move into.
As part of this program they are creating a leadership training program for pathologists who are interested in moving into a leadership role. “It’s important to create that opportunity for growth at all levels,” she said.
Sherrie Rice is editor of CAP TODAY.