CAP TODAY • Phlebotomy program gives lift to lab, community

Originally published by Cap Today

December 2023—The clinical laboratory at Children’s Hospital of Philadelphia is solving two problems at once: its phlebotomist staffing shortage and the need for some in its community to learn a new skill and obtain employment.

In a program for which planning began in 2022, CHOP has partnered with West Philadelphia Skills Initiative, a workforce development program, and Philadelphia Works, a distributor of federal on-the-job training funds, to reach people in its West Philadelphia community who are difficult to find using traditional recruiting platforms.

“West Philadelphia Skills Initiative is connected to church groups and community programs. That’s how they find talent,” says Elizabeth Margolskee, MD, MPH, hematopathologist and assistant professor of pathology and laboratory medicine at CHOP, where she also holds the position of associate chair for workforce resiliency in pathology. When recruiting is done in the traditional way, via Indeed or Monster, for example, “it doesn’t reach everybody,” she says.

“We felt like this would be a nice equity initiative to offer high-paying jobs in health care to people in our local community who have been cut off from opportunity for various reasons,” she says. The only requirements are that candidates have earned a high school diploma or GED, be unemployed, and live in West Philadelphia.

In CHOP’s first effort last year to recruit 10 students, there were 280 applicants, narrowed to 50 for interviews. Training began in January 2023.

The eight weeks of training costs CHOP $16,000 per person, and Philadelphia Works covers half. “We paid $15 an hour and Philadelphia Works paid $7.50 of that,” Dr. Margolskee says. After training, hirees earn $17 to $19 per hour plus benefits.

“Like everybody else, we struggle with staffing in phlebotomy. We have high turnover. We were reliant on temps, which was expensive and bad for morale. They call out a lot,” and there is little recourse, she says. “We had all the same staffing challenges as everyone else, plus the unique challenge of pediatric venipuncture, which isn’t emphasized in training programs.”

As a result, even new recruits with phlebotomy experience had to be trained on the job for eight weeks. “We kind of have to reteach them from the ground up, and we call that CHOP-tizing.” They have to learn to perform procedures on infants, toddlers, and children with autism, among other things. “So we wondered for a long time, since they’re not learning this in school, maybe we could grow our own staff with our own training program.”

That’s what they’re doing now. Kareem Riviere, MSBA, clinical lab technical education program manager, who for years “CHOP-tized” hires and managed quality assurance in phlebotomy, became the lead instructor and has “pivoted from training someone with a traditional background to now training someone with no background,” Dr. Margolskee says.

The eight-week program (five full days per week) is half classroom, half practical, with more of the former at the start and more of the latter at the end. “We worked through every chapter of the textbook, and every two weeks they had an assessment to make sure they were on track,” she says. She and Riviere realized midway they didn’t have sufficient time for one-on-one office hours for trainees who have questions or need additional coaching and a private conversation. So mid-course they made one day of the week an office-hours day for individualized training. All trainees in the program worked toward performing 50 phlebotomy procedures in every age group.

Of the 10 recruits, one was dismissed early on after the background check. Two left the program within days of starting when they realized it wasn’t for them. “They just didn’t like the idea of putting a needle in a baby,” Dr. Margolskee explains. Seven completed the course and were hired.

For the second class of trainees, seven people have been recruited, “because it was hard to train 10 people at once and to leave 10 positions vacant for that long.” In addition, turnover among phlebotomy staff is down in the past six months, from the customary 50 to 60 percent to 30 to 40 percent. Training for the second class of recruits begins this winter.

From the start of the program, Dr. Margolskee’s intent was to use data to monitor the program’s performance, comparing its graduates with the pool of data of 20 traditional hires.

“What we saw,” she says, “is that our trainees were as efficient as a traditional hire after two months of work” in terms of how many patients they can see in the course of a month.

The rates of inadequate samples are where Dr. Margolskee says it gets “super interesting.” Traditional hires had double the rate of inadequate samples as the program hires, who have very low rates. “Some of our traditional hires may have 50 clotted or inadequate quantity samples in a month. Our trainees are much closer to four, five inadequate samples a month.”

All CHOP hires in the laboratory have a 90-day probationary period. Forty percent of traditional phlebotomy hires have their probationary periods extended. “And none of our trainees had to have their probation extended,” Dr. Margolskee says of the seven trained in the new program.

She attributes much of this to Riviere’s teaching. In addition, she says, “They’re exposed from day one to phlebotomy [at CHOP] as opposed to traditional hires who maybe were trained at a different lab, learned things a different way, and now have to relearn.” Program hires know the computer system, how to navigate the hospital, whom to call when they’re in trouble. “I felt like they were more networked into our department from the beginning.”

Even attendance problems were fewer. In this group of new hires, only one had to be issued a first warning for call-outs. About a quarter of traditional hires have an attendance issue in the first six months on the job, Dr. Margolskee says.

People recruited to CHOP from outside the area have to park in a satellite location that’s about a 10-minute bus ride away because there is limited parking space at the hospital, which adds to recruitment difficulties. But for the hires from West Philadelphia, few of whom have cars, it doesn’t present a problem, and it’s a plus on snow days when they can take a trolley or bus to work, Dr. Margolskee says.

No period of commitment to CHOP is required post-training, at least as of now. “We’re debating that. The thought, at least for this first round, was that we don’t want anyone to feel obligated to stay here sticking kids if they don’t like it. It’s unacceptable for someone to be incompetent and unprofessional in front of our patients, so we did not tie it to any work commitment at this time.”

She recalls the trainees saying they were surprised there were no strings attached to a program they didn’t have to pay for. “They felt respected by that,” Dr. Margolskee says. The position may be a “stepping­stone” for some, but that’s okay, she says. “There’s an equity lens to the whole project.” Two of the program hires did leave CHOP after about six months; one now works for a nearby hospital.

Though Dr. Margolskee says “growing your own phlebotomists is more within your reach than you might expect” and “something more groups should lean into,” she admits it’s not easy, and one of her tips is to make sure human resources personnel “have your back” and are aware of the program. In her case, HR staff helped her design a special job description that gave the lab more flexibility. An eight-week course consumes almost half of the 90-day probationary period, which leaves less time to decide if a new hire is meeting expectations. HR’s solution was to create a separate role and to promote the program hires into it.

As associate chair for workforce resiliency in pathology, Dr. Margolskee and two others—the education manager and project manager—create innovative programs to address the workforce shortage in laboratory medicine.

“We think about recruitment and retention and try to address them in a data-driven way,” she says. One retention-focused project, now underway, is addressing the unpleasant phone calls directed at the laboratory staff.

“We’ve been doing a yearlong project to see if we can understand who’s calling and yelling at our staff. What are the things that make them call? Can we give our staff scripts to help them deal with these things? We know that once someone yells at you at work, your mind is not in a good place for continuing with your day, and that creates a risk for our patients.”

A canceled test is a common cause for an angry call. “We learned nurses heard ‘canceled’ and thought their difficult-to-collect specimen was in the trash, when in reality ‘held’ might be a better term—it’s the beginning of finding a collaborative solution, if possible.”

In the meantime, the recruitment initiative in phlebotomy is off to a strong start, and the equity piece to the program is a big part of it. “CHOP really values bridges to the community,” Dr. Margolskee says.

Valerie Neff Newitt is a writer in Audubon, Pa.