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24/7 laboratory service

With round-the-clock working becoming the norm in the NHS, Training Officer Chika K Eze looks at its potential impact for pathology departments.

Demand is at a historic high for emergency and urgent services in the NHS and the traditional nine-to-five, Monday-to-Friday work pattern will not be able to meet the needs of the public. With the workforce not expanding in line with demand, there is a lot of pressure on pathology to increase output, while simultaneously cutting costs.

Most clinical services already have a shift pattern in place. However, the number of consultants available after the traditional hours is still minimal and other grades of staff are also limited during out-of-hour periods. 

In 2013, the NHS Service Seven Days a Week Forum was launched. This aim of the initiative was for all sectors of the NHS to work seven days a week. A report of the initial findings said that people can feel neglected or unsafe, due to low staffing and absence of senior staff at the weekend. 

It continued: “But much worse, much more frightening, is the increasingly compelling, evidence that five-day working costs lives. That your chances of dying are increased significantly because of the simple fact that you arrived there on a Saturday (an 11% increased risk of dying) or, even worse, on a Sunday (a 16% increased risk). 

“And measuring the dead is only one aspect. What of the many who’ve survived but who’ve had worse outcomes than if they had been admitted on a weekday: delayed diagnoses and treatment, more complications, longer stays and more re-admissions?”

Shift pattern and on-call hours already exist in some pathology disciplines, such as haematology and clinical biochemistry. Most medical microbiology labs have started adopting this system, but that is not the case with cellular pathology, which is my background. 

However, there has been a voluntary on-call system in place in cellular pathology in some laboratories across the UK. 

This continuous access to service is achievable, but has an impact on major areas, such as quality, training, team motivation and staff empowerment, which will be covered in this article. 

Many cellular pathology staff believe that a 24-hour-a-day, seven-days-a-week working pattern is not relevant to them. They see their work as manual and many believe that while automation can be used to great effect in some areas, cellular pathology may not be one of them. 

 

Quality 

Emerging issues, such as increased working hours, could present major concerns and will impact on the quality of pathology services, either negatively or positively. Extending the working hours in pathology can negatively affect quality for the following reasons:

Fatigue – There is increased human error when staff are tired, due to the length of working hours and varying shift pattern. 

Skills gap – Not having enough highly-skilled members of the team to cover each shift may impact on the level of quality delivery. This could lead to poor quality-control checks and poor output.

Lack of effective supervision – Due to the unavailability of senior staff members to cover different shifts, there may be a lapse in the procedural standards in place. 

However, there may also be positive impacts on quality as well, for instance:

Continuous flow of production – Continuous access to the pathology service may improve overall quality and, in turn, improve turnaround times.   

Lesser strain – There may be less strain and pressure on staff members to carry out work, as they have more working time. 

 

Training

To maintain a great pathology department, developing the workforce is vital. Extending working hours affects training and has a cost – an impact on both learner and tutor. The negative impacts are:

Staff cover – Cover may not be available for either the trainee or trainer to be able to attend courses. 

This will affect staff development and potentially future productivity. 

Quick implementation – Time required to bridge the skills gap may be insufficient.

Essentially, time required to train people sufficiently to cover shifts may be an issue. 

On the positive side, the training curriculum will have to be expanded in order to accommodate areas that need to be covered in the absence of experienced staff members. This is good news for junior staff members wanting to develop their skills. 

However, I believe that the cons in this instance still outweigh the pros, posing a challenge to training.

 

Motivated workforce

No doubt the new extended working pattern will impact on work-life balance and may not suit some employees. This new pattern may create problems for families that have already created life-work patterns and daily routines. This could adversely affect morale and desire to perform.

On the other hand, it may give some other employees greater flexibility with their work-life pattern. Some people perform better early in the day and others at different times of the day or night. 

Having an extended working pattern may impact on the bond between team members, as they do not regularly work together. As they work at different times, such as early, normal and late shifts, it is less likely that a strong coherent bond will be formed among staff. 

 

Other issues 

There are costs incurred in every reorganisation for service improvement. For extending working time, there will be a cost for training, a cost for quality issues that may arise, a cost for errors and supervision, and a cost for extra power resources required, such as electricity and water. While the available resources, such as manpower, equipment, work ethics, environment and funds, may be strained and stressed due to constant use. In the NHS there can be a culture of staff wanting things to remain the same – people will often resist change. 

Finally, if employees are forced to make these changes in work pattern without due consultations, staff may start exercising their right with reference to their initial contract, which can be complex. 

 

Action plan

This change in work pattern will happen in some laboratories. Therefore, the next step will be working out a suitable action plan that satisfies both the organisation and its employees, as far as possible. The suggested action plan will be a three-pronged, broad-faced approach, revolving around a change management strategy:

  • Effecting a change
  • Monitoring the change
  • Managing the change.

 

People: A competency assessment and manning analysis should be carried out to assess the impact of this change on every individual role within pathology, ranging from the lowest grade to the highest, both scientific and medical. This involves knowing the level of skill required, as outlined in the knowledge and skills framework. Based on the skills framework, the skill gap can be bridged. The number and hierarchy of team members required to cover each shift – for instance how many pathologists (consultants and trainees), senior biomedical scientists (consultants and managers), biomedical scientists (specialists and registered/trainees), healthcare scientist assistants (associate practitioners and HCAs), training and health & safety officials – available on each shift should be brought into consideration. 

Process: What shifts are needed – early, normal and late shifts? The process and procedures in place should be redesigned to suit the current practice. Every new implementation should be documented and authorised. 

There should be effective record-keeping as evidence that staff members are doing their job efficiently.  Every work flow process in the pathology laboratory should be redesigned. Quality management systems, standard operating procedures, check-lists and hand-over documents should all be modified.  

Culture realignment strategy: As NHS staff often resist change, there should be appropriate measures in place before and during the transition period. How do we communicate change? Having a series of meetings and regular consultations with employees will be a good way forward.  

One-to-one consultation with staff members and taking their concerns on board is an aid to implement change efficiently. There is huge need to show empathy as a manager when dealing with each staff member – this will not only boost morale, it will strengthen team spirit. 

An effective manager will need to address every part of the organisational tradition, no matter how unimportant it might seem. Issues such as family life should be scrutinised in the process and a suitable plan designed for those affected. 

Addressing cost: It is important to produce a cost-benefit analysis, which assesses the impact of the extended working system and evaluates the costs and benefits to the service. It is recommended that the pathology managers and other managers are involved in the production and evaluation of this, which would form part of a full business plan detailing all the financial consequences of any new procurement and implementation of changes to support the extended working pattern.

Risk management: Extending the working hours may further increase the associated risks. Therefore, finding appropriate ways to mitigate these risks is essential. A risk-benefit analysis that assesses potential risks that can endanger the project should be produced. Pathology services should ensure that the appropriate equipments are procured for the smooth running of the service and, if possible, a managed service contract could reduce downtime issues. 

A managed service contract is expensive, but no device is error-free and issues will arise, depending on complexity. Operator training, maintenance, analytical quality procedures and record-keeping, including recording patient results, should be monitored in order to minimise risks. It is also essential that the risks associated with the use and the interpretation of results obtained is properly managed and can be successfully achieved by training and supporting pathology staff. Managers should always bear in mind that if this change does not achieve its purpose, they should consider reversing the process.   

 

Chika K Eze is a Training Officer in the Cellular Pathology Department at the Royal Liverpool and Broadgreen University Hospitals NHS Trust Liverpool.

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