National Strategic LaboratoryRoundtableWorkforceWorkstream

Update

November 2016

New ZealandMedicalLaboratoryWorkforce Blueprint

Version#7

Introduction

November 2016

The“Workforce”isalltoo oftenreviewedfroma staticpointof view:numbers in position,vacancies,turnover,compliment,demographicstructureand“demandmet”.Waitinguntildemand isuponus andwe are notcopingforcing a businesscase tobe approved isthemorelikelycurrent mode ofoperation,leavingscantconsiderationtogettingaheadofimpendingdemand.

In highlytechnological industries, whatthefuturelookslike,whattransitioningofworkforcesmayberequired,what currentskillsetsandknowledgewe wishtoretainandgrowaswell asplanningforadaptability, rarelyfeature: succession planninginall butthesmallestof specialties,andproactiveworkforce(re)trainingevenlessso.

Thepurposeoftheblueprint istochangethisasfarasthe laboratoryworkforceisconcerned.Welookat a simpleoverviewof“whatwehavenow”butmainly focus onthedevelopingstate oflaboratoryservices,likelyfuture shapeoftheindustryandhowit can/willdelivertohealthimperatives.Looking athowlaboratoryservicesarechanging,willgiveusachanceto considerwhatadaptation weneed toimplementand ultimatelyto getonwithit.Ratherthanreactingto changewe wishtoplanfor changeand assist theworkforcetodo likewise.

Thisdocumentisintended to be alivingdocument to guideuswhilst remainingadaptiveasourindustryevolves.

CurrentState

AppendixOnecontainscurrent workforcedataanddemographicinformation.Insummary:

  • Thenumber ofscientists and techniciansemployed in themedicallaboratoryindustry overthe past5yearshasslowlygrownfrom3000to 3300.
  • Theratio of techniciansto scientistincreased(moretechniciansrelativetoscientists)from37%in 2005to around48% (justunder50:50)by 2010andhasbeenmaintainedat that ratiosincethen.
  • Theworkforce is primarilyNZtrainedwith72%ofscientistsand62%oftechnicians NZtrained.Themajority of newscientistandtechnician registrationscontinueto comefromNZtrainedindividuals.
  • MedicalLaboratoryServicesemploy apredominantlyfemalepopulation,moreso amongsttechniciansthanscientists.

ChangesintheLaboratoryIndustry

Our visionisthat:

“Clinicalpractice(initsbroadestsense)willbeadvancedbyanintegratedandproactivepathologyandlaboratoryservicethatanticipatestheneedsofpatientsandclinicians,andintentionallymanagesanticipatedchange.”

Andourmission is:

“Thebusinessof putting objectiveevidence(information and intelligence)intothehandsofcliniciansand patients, to enable timely decisionmaking and to improvepatientoutcomes.”

Thismission recognisesthat a significantfocusofPathology andLaboratoryServicesisto enableclinical treatment and caretobedelivered ina safe,effectiveand timelymannercentredonthepatient.Thefocus is alsobroaderthantreatment andcarehoweverincluding such things as:

  • using laboratoryinformationtosupportthe efficientplanning andcommissioningof healthservicesforpopulations
  • informing investment in newhealthtechnology andprocedures
  • the protectionof societyfromharmassociatedwithcommunicablediseases
  • the earlydetection andscreening of disease
  • ensuring that systems,processesandpracticesare inplace toprovideassurancetothe healthserviceaboutthequality oflaboratoryandpathologyinformation.

AppendixTwoentitled“theFutureLaboratory isHere”describesthechangesweknowareeitherimminentor alreadyaffecting laboratoryservices.In thisenvironment,to achieve an integrated andsustainablesystem,clinicalexcellence,quality outcomesand valueformoney,weneedfuturefocusedtraining to be anormalpartofthelaboratorybusiness,ensuringtheworkforce is notjustmaintaining knowledgeand skillbutispreparedtodrive valueaddedchange.Weneedtoretaintheknowledgeand skillswehave inthis workforcebutsupportthem to adaptto changing needs:lesscytologists,morehistologists,morelaboratoryservicecommunicators andpointof caresupportstaff. Itis howwearetodothatin a rapidlychanging environment that isthe focus ofthispaper.

Cytology

Immunisation programmeforHPVhasproduced a60%penetration ofthetargetaudience,and70%vaccineeffectiveness.Theimpactofthispublichealthinitiativetopreventcervicalcancer,plusfurther changesto thescreening programme will havea dramaticimpactonthenumberofcytologistsrequired.It isestimated thatwhenHPVscreening is introduced in2018,wewillneed60-70%lesscytologistsalmostovernight. Butwe willstillneed some,andthose thatremainwillseeahigherpercentage of“abnormals”than currently. Issues thatarise:

  • Withtheclearlackof job security,maintaining a viablecytologyworkforceuntil2018isbecoming difficult.
  • Post2018,whilstfewergynaecytologistswillbeneeded, wewillstill needsomeand theywillneedto behighlyskilled in the abnormal.Note: non gynaecytologywillstillberequired.
  • Lowernumbersofstaffcombinedwithhigherpathological demandmightimposegeographical challenges astowhereservices aredelivered (centralisation).

ACTIONREQUIRED:

1.Urgentattention needsto begivento thisworkforceif wearetoretainsufficientuntil2018:providing comfortaround future jobsecurityneedsto beprovided if thesestaffaretobepersuadedfrom takingthe nextavailable(non lab)jobopportunitythat comesalong.Retrainingstaffin alternativelaboratoryservices,whilsttheycontinueto delivera cytologyservice isoneoption.

2.What the configurationofservices will beafter2018needstobeidentifiedto givecertaintyand sufficienttimetoimplement;specificallywilltherebe acentralisationofservices? Ifweare tohaveoneoftwo morecentralisedservices,where willtheybelocated?If staff aretomovetoa newjob location,they needadvancewarning. Likewiseifmoving isn’ta feasibleoption,maintaining and/or growingaworkforcein thelocation(s)mayberequired.

HistologyBowelScreening

As a resultoftheWaitemataBowelScreening Trial,somefirmerprojectionsof impact ontheworkforce asa result of thisinitiativehavebecomeavailable.Witha populationof575000,keypointsincluded:

–224cancersdetected

–15000peoplescreened

–3.5potsperperson

–FOC(Biochem)reducedneed forcolonoscopyAdditionalWorkforcerequiredas a resultwere:

•SpecimenReception:2.4FTE

•Clerical:0.25FTE

•Scientist/Technician:0.7FTE

•Pathologist:0.5–0.7FTE

Thisresultindicateslessofanimpactonstaffing requirements thanoriginallythoughthowevertheimpactof rolloutneeds to bemonitored.Whethercentralisationofservicesis likelyshouldalsobedecided withoutdelayto givecertainty and thetimetoadapt.

InformationandIntelligence

Howwemanagelaboratorysystems,makesenseofdata andwork“outsidethelaboratory” will beat leastequallyimportantcomponentsofthevaluelaboratoriescan provide.Improving connectivitywith wholeof health and end toendplanning willbecritical. Navigatorsandcommunicatorswith not justdoctors,butpatients,pharmacists,family….will be importantforboththesuccessof thelaboratory(s),butalso the resourcesand knowledgeheld bythem.

Our systemisoftendescribed as datarich butinformation poor.Laboratoryservicesareonesectionof health thatcontains a significantamountof data,bothaboutand forindividualpatientcarethrough tothepopulationlevel.Turning thisdatainto information andintelligenceforpatients,clinicians andthesystem,and communicating thatinformationeffectivelyandefficientlyis akeyrequirementof laboratoryservices.

Thesheervolumewillmandatebetterdemandmanagement systemsaswill increasing expectationaround TAT.But TAT is no longerthetimebetweentaking thesampleand producing theresult. It isincreasinglybeing seen asfromthetimebetween first thinking aboutthetestand clinicians /patientsacting onthe result, whichgivesopportunitytoaddvaluefromwhatlaboratoriesdo. It willbe criticalin gettingthe righttest“thoughtabout”in thefirstinstancethrough to ’whatit means”.And given thatthecustomer will increasinglybe thepatient,mechanismstocommunicateatthislevelwillbemandated.

Informationisa key strengthand resourcethatwill add valuetothe future of patientcentriccare:demand forscientiststoincreasinglywork in thedata/information,quality,clinicalengagementspaceis alreadyapparent.Patientportalsarealreadyin operation giving patientsaccesstotheirtestresults directly:wemustbereadytomeetthatincreasingdemand.

ACTIONREQUIRED

  • Universitiesneedtoensure communication skillsand ITinterfaceknowledge isacorecomponentof laboratorytraining.
  • Training optionsneedtobedevelopedforexisting Laboratoryand ITprofessionalsto ensureexperiencedprofessionalscan contributeinthe newarena

FutureFocusedTraining needs toequip current staffwiththeeffectivecommunication skills aswellashowtoprovideinformation rich resourcesto supportclinical andpopulation baseddecisionmaking.

  • Laboratoryresultsmayneed a redesign if patientsareto makebestuseofthisinformationdirectly.
  • Information portalsandaccesspointsforpatients(livechat,free phone,email,websiteinformationetc.)needto beestablished/improved.

FurtherWorkRequired

InitialTraining

Phlebotomists andothersamplecollectorsneedtobeidentified as aspecificgroup andbesuitablytrained. Thepossibilitythatwherenecessarytheyalso providecannulationservices willassistinsamplecollection andassistotherswithinthehospitalsettingtoobtain the highestquality collects.

Specimenreceiptand processingis becomingmorecomplexandwillcontinuetodo so.Transportofsamplesrequiresstaffto haveahigh degreeofknowledge astobothnationalandinternationaltransportrequirements.Clinical trialsand personalhealth requestswillrequireadvicefromstaffwith thisexpertise.

Technicianscurrentleveloftraining mayneedtobeimproved,focusingon automatedlaboratoryfunctioning.Thismayrequiremoreformaltrainingalbeittothelevelof adiplomaratherthandegree.To makethemostofour workforceand facilitateadaptability aswellas careerprogression,the strandsof learning thatareavailablemustbeableto becreditedtowards subsequent trainingallowingforcareerprogressionforthosethat areabletodoso..

Wemayalsohavetolookatthisworkforceinthe contextof the “scienceindustry”.Demand forlaboratorytechnicians(and scientists) inotherareasoutside ofhealth(privatesectorsuch asoilandgas,horticulture, andpublicsectorsuch asresearchand education).Theability tocrosscreditacrossa widerrangeof skillsetsmayprovidevalue.

Scientists need communication andITskillsjust asmuch as theywill needscientificknowledgeandability.

Future Focused Training

As corebusinessa system needstobeestablishedto provideaccesstofitforpurposetraining that isfuturefocused andpreparatoryforanticipatedchange.

Adaptability

This is a smallworkforceofhighlyskilledpeople.We need toretain theworkforceand giveopportunitiestoadvance ina career,capitalising on priorknowledgeand experience.Wemayalsoneed toexpand thetalentpool fromwhichwe can drawlookingto wholeof science,notjustmedicallaboratoryscience.

TeamWork

All of healthdemandsteam work.In laboratoryandpathologyservicesthepathologist-scientist-technician team is underutilised.Withdemand forintelligenceandcommunication aswell ascoordinationofthe singlepatient’scarethrough toengagementatmultidisciplinaryteammeetings(in communityas in hospitals)betterutilisationoftheteam will berequired.Pathologists andscientistsworking to the samelevelof efficiencyweseefrom (forexample)GPsand nursepractitioners,distributionof tasks,supportand collegialengagementwill assistbetterdeliverytoincreasing demand.

As scientistsincreasinglymoveintotheinterpretationof resultand dataspace,pathologistsmustbewith them to superviseandassistwith theclinical implications.Clearlydefinedscopesof practicewill needto beembeddedin practice.There is also the emerging roleof ClinicalScientistswhowillbeinterpreting resultsandconsulting cliniciansdirectly, andtheroleofPathologyassistants inHistology.

Whole ofindustry

Giventhe changing face oflaboratoryownership andcontrol,and in recognitionof size,thiswillrequirewholeof systemengagement.Retaining people in theindustry, ifnotin thatspecificlaboratorymakesbestuse of resource. To maintain provincialcapabilitywillrequirelargelaboratorycooperation,regardlessofownership.

Wewill needallofthestakeholdersto help to makethejourneyhappen:

  • UniversitiesandotherEducationalProviders
  • ProfessionalAssociationsand Societies
  • Unions and Employers
  • And mostimportantlymembersofthemedicalandscientificprofessionsthemselves.

APPENDIXONE

DemographicData

Thenumber ofscientists and technicians,plusthe ratio,over thepast10years aredetailedbelow(APCdata).

MLT / MLS / MLT/TotalWorkforce
2005 / 928 / 1581 / 37%
2006 / 1264 / 1603 / 44%
2007 / 1232 / 1538 / 45%
2008 / 1397 / 1615 / 46%
2009 / 1408 / 1621 / 47%
2010 / 1520 / 1661 / 48%
2011 / 1549 / 1718 / 47%
2012 / 1526 / 1706 / 47%
2013 / 1542 / 1732 / 47%
2014 / 1577 / 1763 / 47%

Thetrends in pastworkforcenumbers isclearwith increasing numbersof techniciansoverscientists,largelyremaining static.

Howeverinthe2016yearthenumberoftechnicianshaveincreasedduetotheMedicalLaboratoryPre-analyticalTechnician(MLPAT)scopenowcoveringspecimenServices.Thereare173extraatlastcountandlikelyreach200inthefinalanalysis.Thiswillmeantechniciannumbersandtotalregisteredworkforcewillincreasein%eventhoughthenumbersinlabswon'thavechanged.

Thenumber ofNZ graduatescientistandtechnicianversus overseasgraduatesaredetailedbelow.

TheintakeofBachelorMedicalLaboratoryScience(BMLS)studentsfrom2011to2015isdetailedbelow.

MasseyUniversity / AucklandUniversityofTechnology(AUT) / OtagoUniversity
2011 / 108 / 40 / 22
2012 / 119 / 50 / 30
2013 / 127 / 48 / 19
2014 / 114 / 60 / 33
2015 / 110 / 41 / 14
2016 / 31

Furtherinformationthatwouldbehelpful:

  • meaningfulanalysisofhospital,communitysuppliers; and
  • Employer/ownershipimpactonconsolidationof laboratoryservices.

APPENDIXTWO

TheFutureLaboratoryishere

There isalready a“differentview” of howlaboratorysciencesare arrangeddriven fromtechnological advances.Theblood sciencesasopposed tothe tissuesciencesforinstance,suggestsworkforcesableto managea widerrangeof work in whathavetraditionallybeenseen asspecificdisciplines, as adirectresult ofthemerging oftechnological processes.

Wewill seeincreasing need for technicianstobe themainworkforcerunning highlyautomatedlaboratoryservicesalbeittherole ofscientists inmanagement,overall supervision andqualityassurancewill continue.Within highlyautomatedlaboratoriesit istechnologythat is drivinghowworkis segregated.

Howeveratthe resultsendofthe processtheanalysisandinterpretationwill bynecessityremaindisciplinespecific:nomatterhowthemicroresultisobtained, tointerpretthatresult willrequirethe skillsofamicrobiologist(not a chemist).

Closerto Home; directpatientengagement.

PointofCareTesting(POCT):Changes inpractisesuch as being closertohomeandtheuseofcommunityintegratedservicesseePOCTbeginningtogrow.Thiswillincreaserapidlyastechnologyadvancessomaintainingthequalityofthesesystemsaswell as interpretationofoutcomesbysuitablyqualifiedpersonnelwillbeincreasinglyrequired. Desiredoutcomesinclude“closertohome”,resultsthatcorrelatewith laboratories,pieceofmindtechnologythat issupported andcheckedbylaboratories(with nocommercialconflictof interest).

Howthe resultsareproduced(technologydriven)willdemand a differentworkforcedistributionfromhowtheyareinterpreted andcommunicated.Thelatter willstillrequire a high degreeofdisciplinespecificknowledge,team workbetween differentdisciplines andtypesof practitioners,and communicationskillscapable ofeffectivelyengaging with clinicians andpatientdirectly.

Forinstance, inthe areaofcancerdiagnosis,treatmentand maintenancewehave the spectrumofhistological diagnosisofdisease,companiontesting,interfacing both with clinicians andwiththepatientwhoincreasingly isbeing managedathome often in conjunctionwith pharmacyinputandperiodicallyin amaintenanceandmonitoring state.

Providing directlaboratoryfeedbackto patientsthrough ITportalsis uponus:howweassist thepatientto makebestuseofthat information is akeyelement tosuccessfullytreating patientsclosertohome.

Provincialand TertiaryLaboratoryServices

What willbeneeded ina largereferencelaboratory asopposedtogeneralistworkforce in provincialsetting andhowbothskill setsaremaintainedwillof necessityalsobedifferent.

CentralLab
Scientistsmanaging the systems / vs / Provinciallab
Roleextensionforclinical scientist’s / multiskilledscientistsandtechnicians,
Techniciansdoing theroutinework / Clinical scientists/shortage ofpathologists
Within thesystemsPOCT / Pointofcaretesting
Pointofcaretesting

Workareasforthroughputwillbe increasinglytechnologybasedwith the disciplines “hung off”the technology:

  • BloodSciences
  • Tissue
  • Molecular
  • Infection
  • PointofCareTesting

Immunoassay

Biochemistry

Blood SciencesHaematology/ morphology / flowcytometry

CoagulationToxicology/chromatography

Blood Bank/SpecialistTransfusion Services

AnatomicalPathology(histology /gynaeandnon-gynaecytology/ EM).

Tissue ScienceMolecular

Forensic/ coronial/perinatalpathology

MolecularFISH,/cytogenetics/non-invasivepre-nataltesting/ Micro-array / Massiveparallelsequencing/linersequencing,digital PCR.

InfectiousbacterialandviralPCR/Automation/manualculture/ mycology/parasitology/emerging diseases

Whatfollowsisabreakdown ofsomeofthefactorsaffectingdisciplinesastheycurrentlyexistinour laboratoryservicestogiveanindication ofthequantityanddirectionofchangeuponus.

Microbiology

  • Virologymoving to microas PCRincreasesand driveschange
  • Molecular -PCR
  • Increaselinksto:

-PublicHealth/InfectiousDisease/ Pharmacy/Communicabledisease

  • Speed ofdisease,surveillanceand responsiveness(24/7)–isolationmechanisms
  • Emerging diseases,resistantbacteria,viruses
  • Increased automation,increased responsiveness,TAT‘sespeciallycontainment/directpatientvalue.
  • Improveduse of dataand informatics

BiochemistryandHaematology

  • Increased automation
  • Morevolumewithconveyorbelttechnology.
  • Differenttechnologyi.e.POCT,Digital Haematology
  • Increased useofMassspectrometry
  • Surveillance
  • Whatitmeans?
  • Artificialintelligencesupporting testing anddiagnosis/monitoring aswellas usedtoprovidewider interpretiveinformation.
  • Processharmonisation acrossseveral disciplines

BloodBank

BloodBank

  • 24/7Services
  • Potentiallypatientblood grouping willbeintegratedintocentral robotics in5 yearhorizon–BloodBank
  • Decreased demand forredcells dueto improvement in bloodmanagement atpoint of use

SpecialistTransfusion Services

  • Bloodcollection focusedon Plasmadonationsduetoincreased demand forimmunoglobulins
  • Stem cell harvesting,processing andstorageincreasing
  • Newproductsand servicesbeing requestedoftheServiceeg serum eyedropsproduction
  • Potentialto manage theBonesupplynationally,-testingand storage
  • Impactofthe updatetotheHumanTissuesActontissue andboneactivitiesnationally
  • Changing technologyforTissueTyping andRed CellReferencelabsusing genomics
  • Increased needtoidentifypathogens in bloodsupplyearlierand certaintyof clean bloodproducts.
  • Morefocuson processimprovementmethodologiesinall areas
  • Pathogeninactivation technologymoving mainstreamtoimprovethesafety of bloodproducts

AnatomicalPathology

  • Increasing pressureonTAT
  • Companion diagnostictesting
  • Increasing work
  • ageing population
  • increase incancer
  • Increasing complexlaboratorypathways
  • Molecular histology(tumourgenotype)
  • DNA thatcausedthe tumour–outcomesor treatment
  • DigitalPathology–transmissionof datavisually
  • FNA’s- assessingqualityofmaterial taken,rapid assessmentofmaterialforfrozen sectionsetc.

Cytology

  • Decreasein gynaecytology,transition ofstafffromgynaetonon gynae
  • Increase in non gynaecytology(cancer,FNA)butoverall decrease in staffing requirement
  • Increase inDigitalPathology
  • Scientists developingmoreexpertskillsdoing taskspreviouslyperformedby Pathologists

ITCapability

  • Robotics–willtheyreplacetechniciansor increasethenumberof techniciansrequired.
  • Increasing knowledge –increased numberof scientistsrequired.
  • Increasing patientknowledgeand interaction.
  • Useof information–our productisinformation (vsdata)/interpretation /patientfocussedand interfacing withpatientsand clinicians.

EmergingDisease

  • Change in population
  • Olderpopulation
  • Increasein diseasese.g. Haemogloginopathies.
  • Increase in non-invasivepre-nataltesting (fordowns,geneticdisorders)