For our second “State of the Industry” survey topic in 2022, Medical Laboratory Observer (MLO) selected Lab Management Best Practices as its focus. We gathered responses from 189 clinical laboratory professionals with 64% of respondents in director, manager, administrator, or supervisor positions.
The survey results show how the COVID-19 pandemic, continued staffing shortages, and supply chain disruptions have impacted clinical lab operations and revenues. It also reveals some of the most popular approaches for addressing these challenges, from talent recruitment and retainment strategies, to the implementation of automated technologies.
To bring the data to life, we interviewed U.S. clinical laboratory leaders and lab suppliers and service providers to gain their perspectives on the state of the industry. They shared their personal experiences and voiced their opinions on what must change to sustain lab operations moving forward.
Recruiting and retaining staff members
Staff shortages are placing intense pressure on clinical laboratories as they struggle with high demand for testing and the desire among clinicians and patients to get accurate results quickly.
“We’ve taken a hard hit in staffing levels from losing individuals to retirement, new techs who decided they didn’t want to stay in the field, and others leaving for jobs with higher pay,” said Aaron Hurst, Laboratory Supervisor for NMC Health in Newton, Kansas.
Tim Schroeder is Director of Lab for Mahaska Health, a 25-bed critical access hospital in Oskaloosa, Iowa. His team of fewer than 20 FTEs runs 24/7 testing for the hospital and for 40+ hospital-based providers through clinics and two satellite facilities, averaging 500,000 tests per year.
“Even before the COVID-19 pandemic, we were four FTEs short,” said Schroeder. “Just the raw number of hours we have to cover in a week is 300. I’ve had three people out at once with COVID for two weeks – a lab assistant and two techs – so everybody must juggle. At times, I’ve been working benches at 6 a.m. and other days stayed working benches until 7 p.m.”
The survey results show that labs across the country are facing these same challenges, with 76% of respondents saying they have had multiple staff members out sick with COVID-19 at the same time, up from 60% in 2021.
Competing for talent
Lab leaders are challenged to retain current staff members as they face fierce competition from other labs offering better pay. Others noted how lab professionals are increasingly leaving the field to pursue careers in other industries with less pressure and better compensation.
Among those surveyed, 27% said their labs experienced budget cuts due to lost revenue from elective procedures and tests, causing temporary staff furloughs and 24% hiring freezes, making it difficult to hire more staff.
Panton said larger health systems in her area have been able to increase wages while smaller facilities don’t have the resources to match these higher pay rates. Smaller labs were even competing with retail COVID test sites and reference labs for techs during the height of the pandemic.
“We had one local hospital lose three phlebotomists on the same day because they got a $10/hour raise proposal to go to another place. I lost two phlebotomists who left for an extra $10/hour. When the grocery stores were offering an extra $5 per hour in COVID hazard pay, the people in the lab asked, ‘What about us?’”
Other major roadblocks to staffing include fewer staff members in non-SARS-CoV-2 areas of the lab, making it difficult to meet turnaround-time goals (44%), fear/anxiety among prospective job candidates about working in a lab during the pandemic (36%), and more staff than usual assigned to the pre-analytical area to keep up with SARS-CoV-2 tests (33%).
“We brought in some recently graduated phlebotomists during the pandemic, but as soon as they saw the PPE they had to wear, they didn’t do well and left in fear of the COVID-19 patients they were testing,” said Panton.
Real-world solutions to staffing
Continuing education was noted as a popular option for retaining and recruiting staff with 60% of respondents saying their labs have pursued this route, up from 42% in 2021. More than half (53%) said their employers have offered financial incentives (sign-on bonuses, merit allowances, retention bonuses). Other tactics include:
- Partnerships with local colleges and tech schools to offer internships in their labs (44%)
- Shift changes to offer employee scheduling flexibility (44%)
- Efforts to address safety concerns, such as repetitive stress injuries and injuries from sharps (43%)
Panton and her team launched a medical lab technician (MLT) training program five years ago in partnership with two colleges to address staff shortages, taking on four-to-five MLT students per semester. She comments:
“I was told a couple of years ago that, in California, there were 66 graduates of MLT programs entering the workforce each year while there was expected to be 6,500 potential openings in the next five years. Taking on students was not easy on our staff, but once the students had basic training, they were able to be helpful. A lot of schools let students go during the pandemic, but we allowed them to work so they could continue their training.”
Hurst says his lab has put in place programs and processes to help grow their own technicians. They provide tuition support and scholarships to phlebotomists who want to go back to school to become lab technicians, provided they stay with them for a specified number of years following graduation. They have also brought in lab aids who can handle basics tasks, freeing up technicians to run tests and discern results.
At Mahaska Health, Schroeder says he has successfully identified and hired technicians through networking both in the U.S. and beyond its borders. He recently hired a local tech recommended by one of his staff members. In his past positions, he had hired techs from the Philippines, and they, in turn, have recommended others for employment. He is currently in the process of hiring two additional Filipino techs.
Of those lab professionals who participated in the survey, 17% said their employers have offered perks, such as free parking, onsite gym, onsite day care, and reimbursement of public transportation costs, to try to recruit and retain staff members.
Panton acknowledged that keeping staff members happy is a challenge, particularly when the lab can’t offer higher wages, and shared her approach focused on providing flexibility:
“The lab is dynamic, and personnel is your number one factor. I would put out the schedule six-to-eight weeks in advance while a typical hospital would put it out two-to-four weeks in advance. That way, my staff members had plenty of time to tell me what days they wanted off around their other jobs and personal lives. If they had any desire to make a change, they could trade among themselves without limit. We had to make daily adjustments to workload, but having the template helped everyone significantly.”
The establishment of clinical ladders (structures to encourage professional development, such as from novice to expert) is a popular technique for staff recruitment and retainment, with 33% of those surveyed saying their labs have pursued this, followed by implementation of succession-planning processes that offer additional responsibilities to top performers and measure results (22%).
Addressing supply chain disruptions
Two years into the COVID-19 pandemic, the clinical lab industry is still feeling the impacts of supply chain disruptions and shortages.
When asked what best practices they have implemented to address supply-chain issues during the pandemic:
- 58% of respondents said they have utilized multiple testing platforms
- 51% have implemented standing orders (instead of just in time) for crucial supplies
- 47% have worked with state public health officials to gain access to needed testing supplies
- 22% have re-vamped product-evaluation process to measure performance of new supplies and new vendors more accurately
- 19% have switched to reusable types of personal protective equipment (PPE), such as moving from disposable to reusable lab coats
Hurst’s lab has implemented multiple platforms to diversify its testing options. That way, if they face allocation or shortages for reagents for one modality, they can switch to another.
“Just-in-time (JIT) inventory during a pandemic is not effective,” said Hurst. “Nobody could get enough PCR tests. It has been a nightmare. The number one lesson learned is that labs must be proactive instead of reactive to get what they need.”
Getting creative with ordering
Schroeder described how his lab installed a PCR testing platform in December 2020, which his team validated via a Zoom meeting with the manufacturer. At the time, they were only able to secure enough reagents to perform validation testing because the kits were on allocation with the manufacturer. The manufacturer began supplying additional reagents in April/May 2021, but the amount was still not enough to meet the lab’s testing demands. Schroeder knew he had to get creative with his ordering strategy.
“I ordered 700 kits (7,000 tests) from the manufacturer, a 500 kit order to ensure that I would receive adequate allocation to perform needed patient testing.”
In another case, Schroeder ordered kits for the lab’s molecular platform used to run strep screen confirmations. Although the lab was performing 50 of these tests per day, the distributor sent them only 25 tests total.
“I ordered 10 kits (250 tests) from the manufacturer, but they only sent me one kit (25 tests) because they were on allocation. We were performing 40-50 tests/day. I called and talked to my sales rep. He said they only sent one kit (25 tests) because we were a 25-bed critical access hospital, and I explained how our lab does 6,000 strep tests per year and needs 10 kits per week. I got in touch with the testing platform’s national product manager, and we were able to place an order for 100 kits (2,500 tests), which is a five-month supply for us. I was told that the company actually brought in people and paid them overtime to fulfill our order.”
Collaborating with suppliers
“Labs are always looking to vendors to help them, but it is also important that we help the vendors,” said Hurst. “Early in the pandemic, our lab offered to perform studies on COVID-19 tests for the suppliers of these tests. The benefits were all around: The suppliers had a lab to help validate their modalities and we had access to tests for COVID before many others did.”
“We’ve found labs and their suppliers need to stay a step ahead of supply chain issues in order to be prepared,” said Bishop. “[With regards to labels], the best way to do this is ensuring labels are ordered as early as possible, because many raw material shipments are being delayed and production lead times are extended.”
“Another way to prepare is to qualify secondary label materials that withstand your specific lab processes,” Bishop added. “Ask your label supplier to identify alternatives to your current labels - then test them thoroughly. If your current materials become difficult to acquire, you’ll have another option ready to go.”
Bishop says Electronic Imaging Materials sources from multiple suppliers, in multiple geographic locations. They work with their lab clients to provide alternate materials that are equal, if not better, in the event of a supplier stock-out, stating:
“Having a back-up material already chosen and vetted will save you crucial time when you need to reorder. Don’t get caught without the necessary labels to keep your lab activities moving.”
Balancing costs and reimbursements
As the American Clinical Laboratory Association (ACLA) states, payers have slashed reimbursements for lab services as the costs associated with providing critical laboratory services – including labor, supplies, and transportation – continue to rise.1
The survey found labs increasingly implementing new information technology (IT) solutions to help ensure reimbursement covers their costs. This includes:
- Solutions to reduce human error (78% for non-SARS tests, 58% for SARS tests)
- Solutions to help keep current with regulations (71% for non-SARS tests, 59% for SARS tests)
- Analyzers that provide walkaway testing to reduce staffing and FTE hours (76% for non-SARS tests, 53% for SARS tests)
Improving revenue capture
The lack of knowledge and/or IT systems to bill for services correctly is a major challenge to lab revenue, according to Jim O’Neill, Laboratory Services Business Development Manager, Advanced Data Systems. He stated:
The survey results correlate to O’Neill’s observations, with 40% of respondents citing lack of interoperability between their LIS and revenue cycle management software as a stumbling block, 38% lack of software to automate tracking/analysis of costs, and 37% insufficient staff time.
O’Neill says another roadblock to reimbursements is the inability of labs to collect, from referring physicians, appropriate and complete information required by payers, including medical notes.
“Labs must look at their internal systems to make sure their LIS front end system or their middleware company has the appropriate tools to collect the required billing information to get paid from the different payers,” he said. “They should look at integrating data to flow from the LIS or middleware vendor to the billing company with regards to lab reports, requisitions, and doctor and patient chart information/medical notes.”
Coding frustrations and modifications also continue to challenge lab professionals, with 80% of survey respondents indicating they had taken steps to alleviate these issues, including the creation of standard lab processes and staff education materials (78% for non-SARS and 66% for SARS testing) and standardized instrumentation workflows and checklists (77% for non-SARS and 57% for SARS testing).
Higher deductibles and co-pays mean more lab revenue is coming directly from the patient, and labs struggle financially from patients not paying their bills in a timely manner, according to O’Neill. He says staffing shortages have forced labs to get more creative with how they attempt to collect on these payments, stating:
“More labs are sending patient notices via text and email as an alternative to lab billing staff stuffing hundreds, if not thousands, of envelopes on a weekly or monthly basis and paying higher postage rates to mail them.”
Uncovering new savings opportunities
Those surveyed said they are also finding new savings opportunities to help maximize reimbursements and revenue. The majority (81%) said they have adopted processes to review savings opportunities for non-SARS testing, such as evaluating analyzers on a regular schedule (46% for SARS testing). The implementation of ongoing waste and efficiency studies to find potential savings in overhead is another key initiative among lab professionals, with 79% having taken this action for non-SARS testing (43% for SARS).
With regards to efforts to improve inventory control and consumable supply costs:
- 75% evaluated inventory levels for basic supplies, such as assays and controls/reagents
- 53% worked with supply chain management on supplies that are on group purchasing organization (GPO) contracts that offer additional savings
- 37% developed supply utilization tracking and record keeping
- 36% worked with other members of the organization, such as the Chief Medical Officer (CMO) and physicians, to standardize test ordering throughout the organization
- 19% implemented vendor-managed ordering
- 15% developed ongoing review comparing supply reports to the number of invoiced tests
- 13% gained access to electronic inventory tracking from the supply chain/materials management department
- 10% implemented lease agreements that do not include volume commitments
“Labs can’t control consumable supply costs, but they can use nontraditional vendors if they perform the proper vetting,” said Hurst. “We were able to get many needed supplies this way.”
Implementing new tests and technologies
When asked what technologies their labs prioritize in their capital budgets, 68% said technology needed to improve quality/reduce costs, 53% technology needed to remain competitive, 48% technology needed to cover staff shortages with automated equipment, and 45% technology needed to cover broken equipment.
Hurst said his lab’s implementation of an automation line in December 2019 has helped the team navigate the challenges of the pandemic in terms of high testing volumes and low staffing levels. The lab has long seen the value of automation, having automated its blood bank to be completely paperless back in 2007.
The survey findings revealed that close to one-quarter of labs had automated manual processes in the pre-analytical phase of testing (24%). A similar number had implemented evidence-based test utilization backed by data (24%) and/or implemented a pre-approval program for tests that are send-outs (23%). Slightly fewer (17%) had purchased additional centrifuges to reduce bottlenecks in testing workflows.
As for best practices around adopting new tools for laboratory automation, such analyzers or software, 63% said they have analyzed workflow processes for proper space planning, 51% involved the IT department early in the process, and 29% designated a project manager to coordinate short- and long-term planning and implementation with the vendor.
“Every test result impacts patient care. Lead with the medical value of the tests you want to offer – tests that provide quality results. Performance stats beyond best case scenarios may be difficult to come by, but be sure to ask your vendors about mean up time and recalls in addition to the number of tests per hour.”
Fantz recommends that labs consider their institution type and size when evaluating analyzers. “[Question] whether the reagents can be shared across a family of instruments to be more efficient and harmonized to share reference intervals at sister hospitals to reduce interpretation error and improve patient safety.”
“Menu can impact efficiency,” Fantz added. “If you need a second analyzer to run a complete panel of tests, that is likely to make your lab less efficient and cost more. If the test needs to be sent out, delays could impact the patient and increase the chance the result is lost or never seen by the ordering provider.”
With regards to improvements in the quality and efficiency of testing, more than half of those surveyed (65%) said they had standardized test ordering procedures and formularies, while 32% said they had programmed hard stops or other functionality into electronic health records (EHR) systems to guide physicians’ test-ordering practices.
An important step in introducing new software is verifying that changes do not detrimentally impact patient results, according to Fantz. She states: “Human factors engineering and consulting with your manufacturer may help labs consider implementing the right safeguards necessary to ensure patient safety.”
Training staff on new technology
As staffing shortages are a major challenge throughout the industry, we asked lab professionals what best practices they have developed to train staff on new software.
At the top of the list was the creation of standard workflows for all lab employees (60%), followed by the creation of a train-the-trainer model (52%). Also noted was the development of mandatory training for new lab employees that is led by the IT department (25%), development of lunch-and-learn training sessions (15%), and sending a lab person to laboratory information system (LIS) school to develop an in-house expert (14%).
With high staff turnover rates, lab leaders must also take into consideration the training of new staff members on equipment, both old and new, to maintain the quality and efficiency of operations despite changes in personnel.
“Many lab techs point to having a very strong training process that encourages repetition of tasks under supervision, before they begin to do tasks without supervision,” said Maggie Morrissey, Director, Recruiting and Staffing Services, Lighthouse Lab Services. “Regardless of the new employee’s experience, sometimes one lab might practice one technique and one lab might use a different technique. Making sure that lab staff/management is always available for questions or concerns and encouraging questions be asked to prevent mistakes from being made.”
Making improvements for the road ahead
Clinical labs will likely continue to struggle with staff shortages and supply chain disruptions for quite some time, and nobody can predict the trajectory of the COVID-19 pandemic. When asked for their recommendations on how to alleviate the burden of these challenges moving forward, those interviewed offered these thoughts.
Improve lab culture
Work culture is one reason why lab professionals leave one employer and go to another, says Morrissey. She recommends labs take steps to establish cultures that appeal to staff members’ both personally and professionally.
“We often hear candidates say they don’t want to work at specific companies because of poor culture,” said Morrissey. “Reevaluating culture, benefits offered, and other ‘soft’ aspects can really help with attracting new talent. One Lab Tech told me: ‘They need to make the work environment more exciting. Do fun activities for lab week. Have a free lunch once a month or every other week for the employees. Also, make sure employees are not sitting around doing nothing for hours. Make sure there is a plan set, so techs know what they are going to do from the moment they clock in.’”
Further define career paths
Panton says most of the MLT students who participated in her former lab’s training program expressed interest in becoming clinical laboratory scientists (CLS), but the state of California doesn’t currently have a clear pathway to transition from MLT to CLS. She encourages the development of these career pathways, explaining how her team took steps in this direction:
“About halfway through MLT student training, we gave them the opportunity to work as clerks so they could learn the front desk. Some wanted to learn phlebotomy, too, so that helped. When they graduated, they took their exams, and many stayed about 18-to-24 months so they could get into CLS programs and be potential CLS for us to hire upon graduation.”
Increase lab automation
Hurst expressed his surprised at how so few labs, similar in size to his, have embraced automated technologies. He says automation of lab processes has “really saved” his lab during the pandemic, and encourages others to do the same, stating:
“If you don’t think you can afford it, you can.”
“Front-end automation, no reagent preparation, minimum number of calibrations, and quality control, middleware, and automated storage and retrieval can help labs address staffing challenges,” said Fantz. “But labs aren’t commodities. Behind every test, is a patient and behind every test result, is a laboratorian. Together, operational efficiencies, quality instruments and assays coupled with digital solutions and dedicated laboratory professionals deliver the highest quality patient care.”
“They say be loyal to your main distributor, but at the same time I have had to buy things from anybody and everybody to keep the lab running,” said Schroeder. “You have to be loyal but also think outside the box.”
Schroeder recommends leveraging existing relationships with distributors and manufacturers, but at the same time, exploring new partnerships. He says when a lab is facing supply shortages, it can be hard to establish a new relationship with a distributor or manufacturer in the moment. Instead, he suggests labs be proactive and place orders with various suppliers on a regular basis. That way, those suppliers will be there when the lab needs them.
Secure RCM support
O’Neill says revenue cycle management (RCM) is a top concern and challenge among Advanced Data System’s lab clients. Staff shortages make it harder to manually process billing and keep up with payers’ changing requirements. He sees more labs engaging with RCM service providers to perform these tasks on their behalf.
“The comments we are hearing from customers are number one staffing shortages, then the lack of system integration, and lack of experience with regards to correct panel coding and keeping up with regulatory changes with the insurance companies,” said O’Neill. “In the past year, we have had a 37% increase in customers requesting RCM service versus licensing our product to do their own billing in house.”
- Reimbursement & Coverage, American Clinical Laboratory Association (ACLA). https://www.acla.com/reimbursement-coverage/ Accessed April 18, 2022.