A question on an employment website message board asked: Is it better to work in a small or a large lab? An overwhelming majority of respondents preferred larger hospital or reference labs. One person said, "In reference labs you usually don't have to deal directly with doctors, nurses or patients. You usually have a client services department that deals with them. And you don't have to stick patients/draw blood. In small hospitals, with rare exception, you have to draw blood and may have to do esoteric things like EKGs, blood gases, assist with bone marrows and therapeutic phlebotomies for people with polycythemia... Been there and done that, and it's not something anyone should want to do if they have a choice."

Glenda Howard, who has worked in various hospital laboratories for 29 years, is now an administrative director of a small hospital lab. As such, she wears many hats. ""I am QA manager, operations manager, LIS specialist, bench tech and phlebotomist," she said. Not surprisingly, staffing tops the list of challenges for Howard. "Our workforce is aging and everyone must move and multitask." But due to common aging ailments like bad backs, bad feet, etc., her lab staffers sometimes miss work for treatments or recuperation. "Consequently, I spend a lot of time covering their benches and have trouble getting to administrative tasks."

Steve K. Lail, BS, MLT (ASCP), lab manager at Coulee Medical Center in Grand Coulee, Wash., also finds staffing a major challenge. He has begun to look outside the U.S. for candidates. "Over the past few years we have started to heavily recruit from the Philippines. We are such a small, rural facility that it is hard to recruit techs who do not want to take call or perform phlebotomy," said Lail. "The Filipino techs are very reliable and technically proficient in all areas. We are also working on an agreement with a local college to be a training site. We hope this will provide new hires for us in the future."

Lail takes issue with the idea of a small lab manager being all things to all people. Lail suggested, "One thing that doesn't work is thinking you have to do it all and be responsible for everything. When I first became a lab manager I thought it was my responsibility to do everything from collecting blood samples and performing testing to ordering supplies and doing instrument maintenance. But it's better to delegate these tasks to senior techs," said Lail. "It will make you a better leader and reduce the stress of fulfilling other [supervisory] duties."

John Priest Jr., MBA, MSHS MT (AMT), is laboratory senior manager at Banner Health Community Hospital in Torrington, Wyo. Having listed his top three challenges, they all fell under the staffing umbrella: Getting weekend coverage for microbiology, after-hour call, and hiring PRN techs.

"I am currently training other techs to work the [microbiology] area," said Priest of his self-described solutions. This is workable if "you train techs who have a general interest in working in microbiology. But keep in mind it will take a while." For after-hour call, Priest said he is rotating call opportunities. "Some days no one gets called in, some days it's for one or two hours, and other times someone might work all night," he explained. As for having trouble hiring PRN techs, Priest said he has changed the hiring titles to MLT/MT.

In addition to omnipresent staffing hurdles, these managers also pointed to regulatory compliance as a top concern.

"Regulatory management is just as intensive if you run 10 tests or 100 tests," said Howard. "You still must manage proficiency and competency. I would even suggest that competency is harder at a smaller lab because everyone works in every discipline."

Lail said he keeps on top of regulatory requirements by attending several conventions throughout the year that focus on billing, coding and regulatory seminars. "It's not glamorous and can be very boring," Lail admitted. "But compliance is a big deal in the current healthcare environment and staying informed can save a lot of headaches when your facility is visited by CAP, JACHO or state regulatory agencies."

Rounding out a triumvirate of challenges for small lab managers is the task of upgrading instrumentation and structuring test menus.

"Being able to justify new instrumentation by the costs savings produced and showing increased revenue with new tests being available is a big selling point with senior leadership," said Lail. For example, at his lab, upgraded chemistry instrumentation is expected to result in a $250,000 cost savings over the next five years due to better reagent pricing and reduced service costs. "Getting physicians on your side in this process is very valuable since their opinions carry a lot of weight at smaller facilities."

However Howard said that she is considering scaling back the test menu at her facility. "I am really looking hard at it. Here at our hospital lab some of the tests really could be outsourced effectively, while there are other less frequently requested tests that are needed in emergencies. Finding the right balance is a challenge," said Howard.

The challenges of a small hospital lab are sure to increase, particularly as contractual agreements fall more and more to commercial labs. "We have doctors' offices affiliated with our hospital, and about 70% of their insured patients' testing must go to a commercial lab," explained Howard. "We only get the Medicare and self-pay patients. The ED keeps us busy enough, but a lot of those cases get written off."

Maintaining optimism in a challenging environment is tough, said Howard. "To manage a small lab in a small hospital you need great support from the administration and an active pathologist. And while you work side by side with the bench techs every day, you have to remember you are in charge of making business work."

A small lab "is very much like a family," said Priest, noting that an effective manager is "someone who is detailed orientated, a team player, willing to work the bench, and who can get close to their employees without getting too close."

Lail also weighed in on management style for the small lab. "You have to be able to understand your employees and get to know them and what makes them tick. Having a good working relationship with other department heads and senior leadership will also go a long way in helping you get the resources you need for your department and also to communicate the challenges you may be facing," he said. "The need to have a strong relationship with all the providers can't be stressed enough. In the smaller facilities the physicians and mid-level providers (such as nurse practitioners and physician assistants) have a lot of influence on what happens inside the facility."

Valerie Neff Newitt is on staff at ADVANCE. Contact: vnewitt@advanceweb.com.