Clinical Support Personnel in the U.S. Hospitals: Job Trends From 2010-2014 Patricia Pittman, PhD, Suhui Li, PhD, XinXin Han, MS The George Washington University Health Workforce Research Center Objective Data Source Results Analytical Approach Figure 1. Percentage Distribution of Each CSP Worked Hours Among Figure 2. Percentage Change of Mean Number of Specific CSP Hours • To obtain a detailed and up-to-date picture of hospital-based CSP 2010-2014 Premier’s operational database all CSPs, 2014 in Hospitals by Job Levels, 2010-2014 Quantitative Analysis workforce in the U.S. Radiology Technical Assistant , 1.5% Graduate Nurse 28% • The database contains information on basic facility Physical Therapy Assistant, 1.5% • Examined the 2014 distribution of CSP average worked hours Orthopedic Technician 20% - To understand how hospitals are using CSPs currently Imaging Technician, 1.7% Dietetic Technician 17% across all CSP jobs characteristics, department description, job title and description, Other Clinical Non-Licensed Personnel, 6.5% Graduate Nurse, 1.7% Endoscopy Technician 13% - To explore changes in hospital use of CSPs since the 2010 Respiratory Therapy Technican , 1.9% Monitor Technician 13% and staffing information such as labor hours, expenses, and skill Transporter, 3.3% Sterile Processing Technician 9% • Examined the trends of CSP average worked hours by job levels passage of the ACA Monitor Technician, 2.7% Cytology Technician 6% mix category Other Level-3 CSPs, 2.6% Radiation Therapy Aide 6% in hospitals overall and by 3 distinct units: inpatient units, peri- Anesthesia Technician 4% Medical Laboratory Technician, 3.0% • Data are collected regularly from a subset of Premier’s member Surgical Aide, 2.4% Physical Therapy Assistant 3% operative and ambulatory care units, and emergency departments Level-1 Occupational Therapy Assistant 2% hospitals, which represents over 500 healthcare systems with a Cart Assistant, 2.3% Sterile Processing Technician, 3.1% Radiology Technician Assistant -4% • Examined percentage change in average worked hours for each EEG Technician -6% presence in all 50 states and District of Columbia Cardiac Stress Technician -6% CSP job from 2010-2014 EKG Technician -10% • Final analytical data included 438 facilities, 214 departments, and Medical Laboratory Technician -14% Background Imaging Technician -25% 285 unique job titles Respiratory Therapy Technician -26% Other Level-1 CSPs, Quality Assurance Technician -32% 9.4% Medical Assistant 36% Technical Assistant 22% What Is Clinical Support Personnel (CSP)? Nursing Assistant , Pharmacy Technician 3% 15.0% Laboratory Assistant 3% • CSPs is a portion of the allied health workforce who perform Operating Room/Surgery Technician -1% Discussion Nursing Assistant -5% Laboratory Assistant, 3.7% clinical tasks under the supervision of registered nurses or other Level-2 Patient Care Technician -6% Identification Strategy Phlebotomist -6% licensed healthcare professionals in hospitals Medical Record Technician -17% Mental Health Technician -19% • Hospitals reduced the use of higher paying CSPs while increasing Phyarmacy Technician, 4.1% Medical Transcriptionist -34% • CSPs include Unlicensed Assistive Personnel (UAP), whose Patient Care Cart Assistant 210% those require the lowest education level and remuneration during • Identification criteria for CSP titles was based on the skill mix Level-1 CSPs Technician, 11.1% Other - Clinical Non-licensed 25% primary function is to support nurses, and additional patient facing Bed Controller 20% the study period; Only level-3 CSPs experienced growth in our Level-2 CSPs Phlebotomist, 4.2% Activities Coordinator 7% category and job description in Premier’s operational database Level-3 CSPs support workers that that are supervised by other clinicians Level-3 Surgical Aide -3% findings, while levels-2 and level-1 jobs have been declining over - Inclusion Criteria: 1) Titles that belong to “clinical non-licensed” Other level-2 CSPs, Transporter -7% • CSP jobs typically require anything from an associate degree, to 9.6% Medical Assistant , 4.5% Physical Therapy Aide -11% time 6-to-12 week certified training, to on the job training skill-mix category, 2) Titles with “assistant”, “aide”, or “technician” -50% 0% 50% 100% 150% 200% 250% - It could be part of an effort to reduce labor costs, or attributable OR/Surgery Technician, 4.9% Note: Red indicate CSP jobs that has not been identified by BLS. • In 2012, about 60 percent (9.1 million) of healthcare jobs required suggesting providing supports for diagnostic, technical, and to changes in patient demographics, such as an increasing post-secondary or less degree; this group of workers is projected therapeutic services to other clinical licensed professionals, and 3) proportion of the older patients who require a higher level of to grow to about 11.8 million by 2022, with a 36 percentage-points Jobs that work in clinical or hospital settings Figure 3. Trends in Mean Number of CSP Worked Hours in US Figure 4. Trends in Mean Number of CSP Hours By Levels and Hospital Hospitals by Levels, 2010-2014 Units, 2010 - 2014 personal care (LaMantia et al. 2010, Chaudhry et al. 2013) higher growth rate than physicians and nurses - Exclusion Criteria: 1) Jobs that are universally mandated to be - At alternative explanation could be linked to the minimum Level-1 CSPs Level-2 CSPs Level-1 CSPs Level-2 CSPs - CSPs form a large part of this group of workforce licensed, and 2) Any jobs requiring a baccalaureate degree Level-3 CSPs All CSPs Level-3 CSPs All CSPs patient-to-nurse ratio laws (Cook et al. 2012, Aiken et al. 2010) • A total of 26 unique job titles were finally identified 400,000 120,000 • Despite the overall decrease, the use of level 1 CSPs was Why Is CSPs Important? increased use in EDs over time 110,000 -1.5% • The aging population coupled with expanded health insurance 350,000 - This may be a result of increased acuity of patients admitted to -7.6% 100,000 coverage creates an increasing healthcare demand. Concerns have EDs (Skinner et al. 2014) 90,000 been expressed about the potential shortfall of clinicians, e.g. Classification Strategy 300,000 • The use of non-licensed nursing students, i.e., Graduate Nurses, 80,000 physicians, nurses, and licensed allied professionals, in particular -5.6% is growing 250,000 70,000 -1.2% - This could reflect the use of foreign-educated nurses who, due to their long training periods (Roehrig et al. 2015) • CSP jobs was categorized into 3 levels based on the entry-level -9.3% • The use of various forms of CSPs has been a primary strategy for 60,000 because of the visa backlog for nurses that began with the great educational requirements as follows: 200,000 +0.6% hospitals to manage professional shortages while at the same time - Level-1 CSPs: require an associate’s degree 50,000 recession, may be entering the country with student visas and -3.6% reducing costs (Huston 1996, Zimmerman 2000, Orne et al. 1998, - Level-2 CSPs: require a postsecondary non-degree or a certificate 150,000 40,000 working part time in U.S. hospitals (Pittman et al. 2012) Keenan 2003) - Level-3 CSPs: require a high school diploma and on-the-job 30,000 -6.1% 100,000 training -11.9% 20,000 +24.9% -8.9% What Are Missing in the Literature? • Educational requirements was based on various sources of +6.2% 10,000 information, including requirements reported by BLS, job 50,000 +9.3% -8.6% -5.7% • Limited research on hospital-based CSPs - +19.2% Limitations descriptions from major online job boards, and key informant 2010 2011 2012 2013 2014 2010 2011 2012 2013 2014 2010 2011 2012 2013 2014 - Most research to date has been focused on UAPs, a subset of - interviews with industry experts CSPs (e.g., nurse assistant, nurse aides) that undertakes tasks 2010 2011 2012 2013 2014 Inpatient Units Peri-operative and Ambulatory Care Emergency Departments • Our analysis is limited by the fact that it is a convenience sample delegated and supervised by nurses in hospitals Units • The sample contained a greater proportion of large facilities, • Studies to date have been state-specific possibly stemming from software costs and the availability of - A 1994 study in California found that the use of full-time UAP appropriately trained staff to participate in Premier data collection grew between 1990 and 1992 (Barter et al. 1996). At that time, only Measurement Conclusion, Policy Implications, and Future Research effort 26 percent of responding hospitals required a high school diploma for UAP jobs and 29 percent preferred certification for nursing Labor Hour: The annual average number of worked hours for each • In the absence of representative data on CSPs, this longitudinal analysis demonstrates the importance of examining CSP workforce in greater assistants job title by each facility detail that BLS is able to do - A 2013 study in Washington, D.C. suggests that hiring • Included regular work, overtime, education, meetings, call back • The sheer numbers of these workers suggest that they represent critical job opportunities for Americans and are critical to delivering safe and cost Contact Information requirements for UAPs may have been increased (Jenkins & (excluding on-call hours during which staff are not actually called in) effective healthcare Joyner 2013). All responding hospitals required a high school or and other worked hours, representing the time necessary to care • Our current analysis lays the groundwork for future research to examine how the CSPs relates to hospital staffing, particularly nurses and other Patricia Pittman, PhD, Co-director equivalent degree for UAPs and most also preferred a certification for reported admissions, discharges, and outpatient visits licensed clinicians The GW Health Workforce Research Center as nursing assistant • Able to assess the actual CSP usage in hospitals • Ultimately, future studies should explore the relationship of specific CSP staffing mix ratios to quality and cost outcomes ppittman@gwu,edu.