This study, for the first time in our country, using WISN method in the ISO accredited high volume clinical laboratories of a tertiary care University Clinical Centre of Serbia, has estimated the optimal number of medical biochemists and medical laboratory technicians for the actual workload. The WISN difference indicates a shortage of 20% of FTE medical biochemists and 14% of FTE medical laboratory technicians and remarkably variable workload pressure (inequities in its distribution). Inequitable distribution of medical laboratory technicians is more serious than of medical biochemists across all 13 observed laboratories, as nine laboratories are in deficit of laboratory technicians while five laboratories have a deficit of medical biochemists. This shortage is equally pronounced in Serbian public health laboratories as well , and in other countries, which have analysed the staffing needs of laboratory technicians [14–17].
In the last decade, we are witnessing an explosion of new technologies and solutions in laboratories. However, largely outdated staffing norms leave the issue of inequitable distribution of laboratory workers largely unresolved. As the leader in laboratory diagnostics in Serbia, the CMB UCCS wanted to draw attention to the Ministry of Health Republic of Serbia to revise largely outdated staffing norms and develop an evidence-based staffing norm (staffing standard) using the WHO/WISN methods. In the absence of evidence-based guidelines, the standard operating procedures (SOPs) of laboratory processes are driven in part by regulations, by primary, secondary, and tertiary health care laboratory services, and by the priorities of the healthcare institutions. A person in charge of laboratory services in the UCCS has to identify which laboratory staff categories in which laboratories have the highest workload pressure and correct the misbalances. For that purpose, we have developed the project prospects, including the application of the WISN methods that has helped in identifying the activities of our laboratory staff and to streamline them. This was possible through direct identification of times spent on activities, and creation of a list of activity standards, which supported a systematic structuring of working schedules of the laboratory staff.
Due to advanced analytical technologies in medical laboratories, compared to the period of only ten years ago [19, 20], the job description and laboratory workload, the structure of the services they provide, and the role of medical biochemists has changed a lot in Serbia as well. Today, a biochemist is more involved in post-analytical phase, including verification of laboratory results and release of the laboratory test report and communication with a physician/clinical department (unexpected test results, need for new sampling, reflex testing per sample, etc.) [21, 22]. Medical laboratory technicians are mainly involved in preanalytical, analytical and partly in post-analytical phase of laboratory process, which is in line with the job descriptions of the Serbian laboratory workforce [8, 9].
The laboratory health sector of Serbia has over the years dealt with inadequate numbers and unbalanced skill-mix of the required laboratory workers as well as ill distribution. It was partly due to understaffing in some facilities and overstaffing in the others. Since 2014, only selective employment in the public sector, including health care, has been allowed, while the number of job posts is limited. However, even when the Ministry of Health of the Republic of Serbia approves new employments of medical laboratory technicians, an insufficient number of candidates apply for vacancies. The main reasons for unfilled vacancies and severe difficulties in recruitment efforts could be found in the work complexities, increased automation, and queries for higher salaries for the job of laboratory personnel.
The 2019, a job satisfaction survey  showed that 71.8% of CMB UCCS staff was dissatisfied with the salary and 42.3% with their performance evaluation, and 38.7% face work pressure, while 86.6% were satisfied with work equipment, 82.7% with cooperation with colleagues and 75.8% with superiors, and 77.5% with opportunities for further development/education.
Based on the WHO/WISN method for the 2019 workload, the study proposes new staffing norms in the highly automated medical biochemical laboratories at the tertiary health care level. Our results indicate that maintaining the quality of laboratory work and timely availability of their services with the current staffing is challenged. To balance the staffing to the present workload, these laboratories need an additional 8 FTE analysts and 26 FTE technicians. It is evident that in all organizational units, without laboratory information system and total laboratory automation, medical biochemists and medical laboratory technicians spend much more time on health service activities. However, the introduction of innovations in laboratory diagnostic field could concur with prolonged working time, stress, fatigue, resistance and absenteeism of an already overworked staff, and compromise quality of outcomes. Together with the redeployment of staff or workload to achieve WISN ratio balance, laboratory managers should effectively communicate WISN to gain staff motivation for workforce equity and should promote WISN benefits for CMB UCCS efficiency and quality as well as encourage staff role in upgrading/maintaining competencies.
This study is the first in Serbia that used the WISN to illustrate laboratory process organisation, create a list of health services, support categorical and additional individual activities together with time necessary for their execution, and to develop staffing norms for medical biochemists and medical laboratory technicians in highly automated tertiary level health care laboratories. It provides evidence that could support the fact that the staffing norms cannot be equated for laboratories at the primary, secondary, and tertiary levels of health care, which have different workload, different levels of automation of the laboratory processes or without total automation, as well as with or without laboratory information system.
Laboratory staff shortage, aged pool of the personnel, and the demographic time bomb of looming retirements can only make the situation worse. The impact of inadequate laboratory staff becomes apparent when a delayed diagnosis or error occurs reducing the quality and optimal care of the patient [24–26]. The essential question of management is how to keep well-functioning and efficient medical laboratory organization capable of responding to workload and all challenges, especially to have cohesive and effective laboratory staff . Therefore, the application of WISN analysis in CMB UCCS is particularly important for maintaining and improving the quality of health services and to improve patient safety and patient, physician, and employee satisfaction. On one hand, medical laboratories are under high pressure due to an increased number of patients, expanding test menus and increasing pressure to embrace the accelerated technological advancement such as an installation of total automation solutions and improvements in informatics accompanied by trainings and intensive additional activities. On the other hand, they are facing economic pressure to reduce costs, shortening turnaround time, and improve patient safety.
The study has both short-term and long-term recommendations. Based on the present study, in 2020, we have reorganized the work including the following:
the relocation of a few laboratory workers from low to high workload laboratory unit,
the shift of some current additional activities to other staff,
finishing the digital connection of laboratories to hospital information system,
hiring the additional workers on temporary base, and
recruiting more medical biochemists/laboratory technicians on mandatory internship.
However, due to the COVID-19 pandemic, a new laboratory department of UCCS is established in the newly built hospital for patients with COVID-19 near Belgrade, where the new laboratory staff was redirected, instead of employment in vacant positions in CMB UCCS.
On the long-run, this study recommendation is oriented toward policy and include:
defining positions for separate staff category for administrative/support activities in laboratories,
improving laboratory staff education policy,
increase the number of residency training programs and positions especially at high-level laboratories,
revision of work-based staffing models to ensure adequate staff numbers and skills employed/maintained at the right time and place, and
development of strategies to recruit adequate numbers of laboratory staff.
Also, continuing with further application of the newest technology, total laboratory automation of our lab and application of different informatics solution (analyser management system, inventory management system, etc.) will ease workforce shortages, decrease the working time for some support and additional activities and enable delivery of greater overall productivity with their existing resources.
Adoption of flexible health workforce planning, and recruitment policy based on local patient load and diseases burden plausible future scenarios is highly desirable. More success is expected in workforce policy-making for CMB if these recommendations are in parallel with an integration of multi-site laboratories into one totally automate and fully digitalized laboratory facility. This 2019 study is a baseline study of the impact of the COVID-19 pandemic on the laboratory work during 2020 and 2021. It provides evidence to the Ministry of Health of the Republic of Serbia and UCCS Management’s for the reorganization of the UCCS laboratory service in 2021.
The adoption and application of the WHO/WISN methodology should be viewed as a vital tool in improving strategic health workforce planning and management in laboratory settings as well. In a broader context, the national health system can benefit from the use of the WHO/WISN method, not only in estimating the optimal number of laboratory staff and precisely defining the workload components, but also in revising of the staffing norms, improving staffing equity and productivity across the types of facilities, and estimating workforce requirements for new cadres in the near future.
A few limitations of our study need to be highlighted. Firstly, our survey has covered only the year 2019, and it is possible that attrition trends may vary over the years. Given that at the time of this study there was no digitized database of laboratory staff’s personnel information, data about annual leaves, sick leaves and other leaves were available only in paper form, and the process of obtaining this data was slow. However, to reduce the possible biases we have overviewed AWT and workload data for the years 2017, and 2018 as well. Also, the accuracy of this study’s results is causally linked to the accuracy of the service statistics of CMB. Although we applied the triangulation method to provide valid WISN estimates (the review of laboratory records, the interviews with key laboratory personnel and the observation of laboratory processes and time measurements of laboratory activities), the results of this study cannot be generalised to other laboratories of different healthcare levels (primary, secondary) with different quantity of workload, different level of automation and IT. Medical laboratory staffing plans require periodic revision because of changes in the volume, technology and nature of the activities. Running the WISN assessment every two years can assist in evaluation of management efforts.