David Whipple, MEd, RT, school program director, Jeffrey A. Palmucci, RT, radiology manager, and Godfrey Gaisie, MD, chairman of radiology, Childrens Hospital Medical Center, Akron, Ohio.

Throughout its nearly 30-year history, the radiography technologist training school at Childrens Hospital Medical Center of Akron was a money-losing proposition. So what did the northeastern Ohio institution do about it? Beginning in 2000, it expanded the scope of the school and increased the size of each class of studentsfirst doubling, then quadrupling them.

The result speaks for itself: the school this year turned its first-ever profit. Instead of losing $120,000 per annum as had been customary, the school netted a tidy $25,000, reports Jeffrey A. Palmucci, RT, radiology manager at Childrens.

However, this expansion of the school would have been impossible were it not for an innovative education partnership forged with two other hospitals in the areahospitals that, under normal circumstances, are unyielding rivals.

Prodding these hospitals to adopt a stance of cooperation was their mutual need to undo the harm each had suffered as a result of the nation's chronic shortage of technologists. At Childrens, the first signs of shortage-related problems began cropping up in the late 1980s, when other local hospitals one by one closed their technologist training schools. There were eight separate programs serving the Akron market during the schools' heyday, says Palmucci.

"The hospitals dismantled their tech schools because they had become financial burdens at a time when everyone was scrambling for ways to cut costs," he observes. "Meanwhile, those same hospitals proceeded to open outpatient imaging centers that increasingly expanded to include virtually all of the modalities found on the inpatient side. The introduction of those centers and their subsequent service-line growth fueled demand for technologists and made the shortage grow worse in this region."

REMAINED OPEN

The only Akron-area hospital that did not close its technologist school was Childrens, a 253-bed pediatric facility where the radiology department offers diagnostic and special procedures with modalities that include CT, MR, ultrasound, and nuclear medicine.

According to department chairman Godfrey Gaisie, MD, the money-losing school remained open simply because the hospital needed pediatric-trained technologists.

"Generalized radiology tech schools do teach their students about pediatrics, but nowhere near as adequately as is necessary for working in an institution like ours," says Gaisie, whose department annually performs 75,000 imaging procedures on children. "The only way to ensure that the new technologists we hired would possess the full gamut of pediatric skills we required was to train them right here in our own school."

Adds David L. Whipple, MEd, PT, director of the center's radiography program: "We also never shut down our school because we recognized that to do so would cost the department and the hospital much more than we would have ever saved by eliminating it. The extent to which our radiology department had come to be dependent on student help was quite significant. If we had closed our school, then we would have had to replace all those students with a comparable number of higher-salaried staff technologists or else paid overtime to existing employees made to work much longer shifts to make up for the shortage of hands."

But even with the school, Childrens could not escape the effects of the technologist shortage. Beginning in 1998, Palmucci encountered severe difficulty replacing technologists who retired or switched institutional affiliations. One way he tried to address the problem was by offering financial and professional-development incentives for existing staff in order to keep them from being lured away, thus lessening his need to recruit new personnel.

"I was still able to find replacements; it's just that to do so required much more time and expense on my part," he says. "Instead of spending that time learning about picture archiving and communications systems (PACS)  and doing the things necessary to advance our plans to achieve an all-electronic radiology environment, I was off head-hunting and having to provide special training for fill-in techs obtained through temp agencies."

Palmucci believes that, had this diversion of his time continued unabated, the department's sluggish pace of PACS implementation would have eventually cost the enterprise in terms of its ability to deliver quality care at a competitive price.

"Every day that went by that we didn't have our PACS goals met meant another day in which we were prevented from making images more quickly and reliably accessible at the points of care," he asserts.

Palmucci admits that, at first, he thought the technologist shortage would prove to be nothing more than a short-lived cyclical occurrence, as had been true of those preceding it.

"My initial inclination was to do nothing about it because I imagined it would soon enough take care of itself," he says. "But as time went by, it became more and more obvious that this was a problem that was not going to go away on its own."

Once Palmucci reached that conclusion, he then sought to remedy the problem by initiating for the first time an advertising outreach in cities far afield of the Akron market. He also abandoned previously held objections to using temporary personnel, although the hospital paid a price for his acquiescence on that matter.

"The use of temps ended up costing the department at least $130,000 a year more in agency fees than what we would have had to pay for the same number of technologists were they instead hired as our own salaried employees," he says. "You pay premium dollar when you go through a temp agency, and that's why I had long tried to avoid going that route."

GRASSROOTS INITIATIVE

Things began looking up in 1999, when Whipple took the initiative to explore whether a radiography program with multiple clinical sites would be welcome in the Akron area. In short order, department administrators from two other hospitals responded favorably to Whipple's queries.

"These hospitals were those that had discontinued their tech schools years earlier and now were being punished by the same technologist shortage problems that we were facing," says Palmucci.

It so happened that Childrens at that time had been toying with the notion of enrolling more than the usual class of seven students in its technologist school, hoping that cranking out more graduates would help reduce the department's dependence on agency-supplied temps. But the problem was capital. To enlarge the school would mean a proportionately larger expense for the hospital to bear, and Childrens already was losing money to the tune of $120,000 a year for faculty salaries, books, and other related items.

"Cost had been our stumbling block, but suddenly here were these other hospitals indicating a willingness to share it,"  Palmucci says. "Specifically, they said they would pay the salaries of the additional clinical instructors the school would need if class size were to be increased."

This represented a potentially sweet deal for the other hospitals, Palmucci notes.

"It would have been very expensivenot to mention difficultfor them to restart their schools independently, because they would have had to do it from scratch, given the number of years that had lapsed since they last held classes," he explains. "Their best and most economically sound option was to link up with Childrens and become partners in the one school that was still in operation."

Partnership was possible, Palmucci believes, because the initial rounds of discussion started at the grassroots level.

"The conversations about this partnership began with hospital radiology professionals talking to their peers at the other enterprises in the marketand even though we're at competing institutions, we're still colleagues, we attend the same meetings, move in the same professional circles, and so we have very good friendships among ourselves," he says. "It was entirely natural and appropriate that we should begin talking about finding a common solution to a shared problem."

Administrators of Childrens were informed early on that radiology department representatives were engaged in talks with their cross-town counterparts about expanding the school, Gaisie says. "Our hospital officials said we could proceed with our discussions, but they made it clear that we were to keep them apprised of our progress and to avoid making any binding commitments," he recalls. "Our administrators became fully involved at a much later stage, after many of the key, foundational issues had been settled informally among the radiology teams. I think if we had attempted to do this the other way around, hoping the administrations of the various hospitals would take the lead, the old rivalries would have interfered and prevented progress from being made."

A major selling point to Childrens' top administrators was the promise of an eventual end to big outlays on national recruitment advertising and temporary employees, says Gaisie.

After the respective radiology departments had developed a blueprint for the joint administration of the technologist school, they presented it to their hospital administrations for review, modification, and approval. "The approval process went along very quickly," Palmucci remembers. "Our legal department drew up a preliminary contract, there was some negotiating of the fine points and resolving of differences, and then a final version of the document was produced and signed. It took about 3 weeks for all the details to be ironed out among the players."

Palmucci says that, although the idea of an expanded, jointly administered technologist school was readily embraced by the other hospitals, it still fell to Childrens to serve as the mover and shaker responsible for implementing the proposal.

"Because we're the only hospital really doing pediatrics in the Akron market, we were seen as a neutral party that the two adult-focused hospitals could trust to fairly broker the deal and get things done," he offers. "Looking back, I'm very proud of the fact that we were all able to come together to address a common problem and get it resolved rather quickly and with a minimum of objections."

GROWING CLASSES

A short time later, enrollment opened. Under the terms of the operating agreement, each hospital was responsible for recruiting and admitting five students to the programa total of 15 for the class. The five selected by Childrens would receive the majority of their clinical training there, while the remaining 10 would receive theirs at each of the two adult hospitals. All of the didactic, academic instruction was to take place at Childrens, says Whipple.

The department of radiology chair Godfrey Gaisie, MD, reaps the benefits of the expanded technologist school in the form of new hires.

"The classroom portion of the program was not confined to pediatrics," he comments. "It was a comprehensive curriculum."

Two additional hospitals in the area earlier this year signed on as partners in the program, bringing to five the total of clinical sites where students undergo hands-on training. Welcoming those other institutions into the fold enabled the school to again increase its freshman class size, this time to 26 students.

The program takes 2 years to complete, and yields for each student 50 credits recognized and accepted by the University of Akron. Whipple, whose status is that of a University of Akron professor, himself conducts the majority of the classroom lectures (two other instructors employed as part-time faculty share some of the load on the academic side of the program).

The school is currently operating slightly in the black, the first time ever. Palmucci attributes this to the increased enrollment (which has been accomplished without a concomitant increase in school operating expenses), but mainly he says it is the result of charging higher tuition.

"We formerly charged students $400 per year to go through the program, and we picked up the tab for their books," he says. "Three years ago, we decided to bring the tuition in line with the amount being charged by universities in this part of the country for a comparable amount of classroom credits. Now, we charge students about $3,650 a year, and they have to pay for their books out of their own pockets."

The number of applicants to the school declined by about half after the tuition hike took effect, Palmucci reports. However, he believes that most of the drop resulted when Childrens told admission seekers they would henceforth have to pay a non-refundable $15 fee in order for their enrollment applications to be considered.

"We did this not to increase the school's revenues, but to discourage nonserious applicants from applying," he says. "Every year out of the roughly 200 applications received, there would always be a sizable number of people who really weren't sure they wanted to study to become technologists but who would send in an application anyway. Since there was no cost to them, they had nothing to lose by doing so. But there was a cost to the school, because we ended up wasting time and resources evaluating these candidates. It was important to us to screen out nonserious candidates because of their potential for low academic achievement and their likelihood of not completing the course.

"This year, for the 26 slots open, we received 94 applications, so it's clear that the fee is helping winnow those nonserious candidates."

Students are recruited to the school by means of paid advertising, face-to-face outreach, and word of mouth. "We have a web site (www.akronchildrens.org), which has proven useful in attracting inquiries about the school from prospective students," says Whipple, who regularly visits the University of Akron campus to function as a recruiter (he performs much the same role each time his hospital hosts or participates in community job fairs).

The radiology department also is attempting to attract future applicants by reaching out to them while they are just in elementary school. "I go out to kindergarten and first grade classes and talk about radiology, to explain what it is, to show that it's an exciting field to work in," says Whipple. "I take with me interesting x-ray films. I've got one that shows a patient who had eight toes on one footthe kids go crazy over this kind of stuff. But it plants the seeds in their minds about radiology as a career to one day

look into."

A similar concept is behind the hospital's annual "Ted E. Bear Clinic," in which patients from the floors as well as children from area schools bring in their stuffed animal toys for mock examinations and services delivered by the various departments, radiology among them.

INCENTIVE TO STAY

The first enlarged class of technologists-in-the-making, the one with 15 students, has now graduated. Of the five students who underwent clinical training at Childrens, three agreed to stay on as new, full-time employees.

"In other words, we held onto 60% of the techs we trained," Palmucci enthuses. "That's the highest percentage of retention I've seen in many years."

Graduates who choose to remain with Childrens are hired in at about the same entry-level salary as would any other newly minted technologist trained elsewhere. The starting pay is well below the wage paid to more experienced technologists at Childrens, so the morale-sapping problem of income-envy among employees is not something with which Palmucci must contend.

Nevertheless, graduates are presented a powerful financial incentive to stay, over and above the enticement of a competitive salary. The incentive comes in the form of a second-year tuition-and-book-expenses deferment of up to a combined total of $4,000.

"We call this a tuition waiver program," says Palmucci. "The students who qualify for the waiver get to go to their final year of tech school free of charge. But they still owe us the money. So, the arrangement we make is that we credit them $2 of the waived tuition for every hour they're employed by us, beginning 3 months prior to graduation. That means we're guaranteed to have them on staff for at least 2,000 hours, which works out to 250 8-hour workdays and/or about 1 full year, less time for vacation and holidays.

"At the end of that time, they're free to leave us and work anywhere they want. But the point is that I have a year to make them fall in love with this place and, hopefully, never want to leave."

Students who enter into the deferred tuition arrangement are chosen from a list of applicants developed near the end of their first year of training.

Given that the first expanded class did not graduate until June, it is too early to tell whether the new approach taken with the school will prove a viable solution to the technologist shortage. But that has not stopped Childrens' radiology team from considering ways to make the school bigger and better. For example, there is talk of incorporating within the program an Internet-based distance-learning component, which would permit the training of technologists in other parts of the country where a Childrens-style school would be infeasible for any number of economic and market-reality reasons.

"Were we to go forward with this, and it's far from certain that we will, we'd first need to develop controls and safeguards that will ensure education is occurring with students we can't see and interact with in person," says Whipple. "However, what this idea represents is the potential a school like ours has for the future. I think it's good that we're thinking outside the box with regard to the technologist shortage and are trying in our own way to help the profession of radiology wherever it's being practiced."

Rich Smith is a contributing writer for Decisions in Imaging Economics.