Human resources and laboratory re-engineering: Can we survive it?

Abstract

We are all aware of the new buzz words: hospital networks, delivery systems, re-engineering, consolidation, downsizing. These words signal that the clinical microbiology and indeed the profession itself is undergoing profound changes. In the past, and the past may be just a few months ago, a typical Department of Pathology, at least in many large hospitals, consisted of several divisions (e.g., chemistry, hematology, microbiology) with each division frequently headed by a doctoral level director or chief. In many of these hospitals, the technologists were specialists who worked primarily in their specialty discipline. While automation clearly predominated over manual testing in the chemistry and hematology sections, the microbiology was a mix of manual and semi-automated test methods. The crisis in healthcare and the resulting changes that focus on cost containment and revenue generation have led to a dramatic restructuring of traditional hospital laboratories, which affects both the practice of medicine and human resources. In the budget, supplies or OTPS (other than personnel) consume approximately one-third of the dollars and personnel the remaining two-thirds. Cost savings in OTPS can be achieved through a variety of efforts such as increasing productivity, streamlining procedures, and changing utilization. In the big picture, however, these changes in practice yield only relatively minor cost savings. Major cost savings in OTPS can be made by introducing additional automation, which of itself is often very expensive, but which allows for a tremendous increase in test volume processed with a concomitant decrease in cost per test. In addition, and more importantly, use of automation implies a decreased need for personnel. Because personnel are the major component in budgets, emphasis is being placed here. Waves of Change The first wave of changes affecting laboratories was the consolidation or absorption of smaller laboratories into larger ones. Staffing allocations were already impacted in these first consolidations; the smaller, consolidated often lost staff while at the same time the larger could not hire additional personnel to compensate for the increase in workload. However, once the problems of transporting specimens from one to the other were addressed and the issue of transmitting information back to physicians was solved, this process generally led to better service for the smaller hospital and, in the end, acceptance on the part of clinicians. After all, large laboratories usually offer 24-h service and a wider spectrum of tests than smaller laboratories. However, these consolidations were only the beginning. At least on the east coast of the U.S., we are in the second wave of change. In this phase, large hospitals are rapidly merging into integrated delivery systems and partnerships. The changes seen in the first wave are magnified and accelerated as a result of the realization that there are finite numbers of specimens and patients that any hospital system can lock into. Thus, the process leading toward more consolidations, more automation, higher test volumes with lower costs, and fewer personnel has accelerated. One result of this process has been a blurring of the distinctions between traditional disciplines. At the same time, many laboratories are experiencing significant staff reductions at both the technical and managerial levels. One re-engineering model today is that of a laboratory or rapid-response laboratory organized by similarity of technology (e.g., manual vs. automated tests) rather than by discipline. In this type of setting, what were once thought of strictly as microbiology tests may become divided among other areas of the laboratory. The accessioning and processing of all specimens, including microbiology specimens, often becomes part of the core laboratory. Other functions, such as automated blood culturing and initial smear reading, may also become part of the automated core laboratory, whereas the actual workup of a positive culture, clearly a manual task requiring more skill than that required to simply pull a positive blood culture bottle from a machine, is part of the re-engineered microbiology laboratory. In addition, there is increasing pressure towards use of even more automation and the consolidation of technologies, thereby utilizing the economies of scale. Assays performed in the microbiology laboratory, e.g., viral and other serologic assays, may become part of the core if a chemistry analyzer is available to perform these tests. This decision is frequently made on the basis of financial considerations alone often without the actual level of performance and/or quality of the test taken into account and, importantly, sometimes without the input of a professional microbiologist. Communication then becomes critical. Not only is the question of who is responsible for which tests unclear, but also to whom to refer test result questions and who can answer them.