Convenient truths : empowering employees, empowering energy choices

Convenient Truths: Empowering Employees, Empowering Energy Choices By Aaron Michael Thom

Submitted to the MIT Sloan School of Management and the Department of Civil and Environmental Engineering on May 18, 2018, in partial fulfillment of the requirements for the

degrees of Master of Science in Civil and Environmental Engineering And

Master of Business Administration

in conjunction with the Leaders for Global Operations Program at the MASSACHUSETTS INSTITUTE OF TECHNOLOGY

June 2018

C Aaron Michael Thom, MMXVIII. All rights reserved.

The author hereby grants to MIT permission to reproduce and to distribute publicly paper and electronic copies of this thesis document in whole or in part in any medium now known or

hereafter created.

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MIT Sloan School of Management, Department of Civil and Environmental Engineering May 18, 2018

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Donald and Martha Harleman Professor, MIT School of Engineering Certified by....S

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Zeynep Ton, Thesis Supervisor Adjunyt Associate Professor, MIT Sloan School of Management

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Maura Herson, Director, MBA Program

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MASSACHUSMlS INSUTE4 Jesse Kroll, Graduate Officer and Associate Professor

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Convenient Truths:

Empowering Employees, Empowering Energy Choices

Submitted to the MIT Sloan School of Management and the Department of Civil and Environmental Engineering on May 18, 2018, in partial fulfillment of the requirements for the

degrees of Master of Science in Civil and Environmental Engineering

And

Master of Business Administration Abstract

Journey Health is an industry leader in medical testing, touching a large portion of Americans each year. To maintain this position, the company makes strategic investments in R&D, business development, and continuous operations improvement. The company faces dual challenges in resource allocation nationwide due to high rates of turnover among first-year employees, specifically in Specimen Processing, as well as electric utility bills that, across the company, cost tens of millions of dollars per year and continue to increase as business grows. Each turn of an employee costs an estimated $7,500, accounting for recruiting, training, and productivity losses. The aim of this research is twofold: 1) to examine the causes of employee turnover and leverage the Good Jobs Strategy to develop a solution and 2) to examine the viability of on-site solar generation as a means of cost improvements and other ancillary benefits including the safety and convenience of covered parking.

Nationwide first-year turnover among Specimen Processing Technicians (SPTs) at Journey laboratories averages 50%. Primary reasons for employee attrition included lack of engagement and competing opportunities. The Good Jobs Strategy is a combination of investment in people with four operational choices that leverage that investment by increasing productivity, contribution and motivation of employees and by driving continuous improvement. These choices are: standardize and empower, cross-train, operate with slack, and focus and simplify. I conducted phone interviews and in-person observations with ten Journey locations. Within the framework of the Good Jobs Strategy, I developed a set of recommendations that includes clearly defining job descriptions, increasing opportunities for employees to build rewarding careers, empowering employees to feel engaged and motivated on the job, and

aligning interests across both Specimen Management and Logistics in frontline operations. I also find that the current state of knowledge-sharing across Journey locations can be improved, and that changes to management perceptions of frontline employees is critical for the Good Jobs Strategy to succeed in the long-term.

As an additional initiative, I evaluated the potential for on-site solar generation to be a value-added opportunity at Journey in Westborough, Massachusetts. I estimated that solar production can offset approximately 40-50% of utility consumption and find broad support among employees due to the benefits of having covered parking where the solar panels are installed in the form of carport solar, elevated panels above the parking lots I also estimate that the project has a net present value (NPV) up to $4.9M in Westborough with the internal rate of return (IRR) up to of 12%. I conducted a sensitivity analysis on the input parameters and found a significant influence of precipitation on system output, with less influence by variation in

vegetation height and performance of the solar modules themselves. I find that NPV and IRR may vary significantly, from $3.5-$8.OM and 6% to 19%, depending on installation costs and system output. Critically, I find that a regulatory framework is necessary to require utilities to allow grid connections from distributed solar generation. Also, I find technical and non-financial factors that drive decision-making, including willingness to make capital investments, leased-versus-owned status of property, and familiarity with solar electricity and utility markets.

I found that a clear reframing the discussion in terms more understandable to the client is

particularly useful, such as considering the project separate from solar energy, but more as constructing covered parking for employees, yet being paid to do so. I conclude that on-site solar generation has significant financial benefits for Journey. Although the estimated payback period of four to ten years is longer than Journey's typical capital investment payback, solar offers a low-risk form of investment. Alternate installation models may be investigated, including a leased model, which would require no upfront capital investment by Journey.

Thesis Supervisor: Heidi Nepf

Title: Donald and Martha Harleman Professor, MIT School of Engineering Thesis Supervisor: Zeynep Ton

Title: Adjunct Associate Professor, MIT Sloan School of Management

Acknowledgements

This research would not have been possible without the massive support of my incredible supervisor at Journey, who enthusiastically encouraged me to learn as much about the company as possible and to set my own direction, with his guidance. I would also like to thank the numerous Specimen Processing Technicians, Group Leads, Supervisors, Trainers, Executives, and Human Resources employees at the many Journey locations that gave me their invaluable time to provide guidance and insights into Journey operations.

My advisors, Heidi Nepf and Zeynep Ton, have given me so much guidance and

feedback throughout this research, challenging me to think critically about how to approach this opportunity. Heidi was boundless in her technical knowledge and helping me to scope my project, while Zeynep helped me to understand how to take the Good Jobs Strategy as she

describes it in her book and apply it to Journey Health. Because of them, my eyes have opened to things I didn't before see.

Then there's the LGO crew for making sure I would check all the boxes to graduate, finding me a pre-match internship, and giving me the opportunity to participate in a short film. Without their

support and guidance through the stages of executing a proper thesis, I'd be adrift. And finally, I'd like to thank my LGO peers, for reminding me to have a sense of levity, and a sense of

Contents

1 Introduction and Opportunity Statement... 10

1.1 General Opportunity Statement... 10

1.2 B ack ground ... 12

2 Research Methodology and Findings... 18

2.1 Site Visits, Employee Interviews, and Data Collection ... 18

2.1.1 Summary of Relevant Specimen Management Organizational Structure and Career P ath ... 2 3 2.1.2 Operational Overview of Specimen Management ... 25

2.1.3 Specimen Processing Technician Job Description ... 27

2.1.4 Common Challenges for Specimen Processing Technicians... 29

2.2 T racking T urnover... 30

2.3 C auses of Turnover ... 31

2.4 L iterature R eview ... 37

3 Application of the Good Jobs Strategy to Reduce Turnover and Improve Performance... 40

3.1 Opportunities to Invest in People ... 40

3.1.1 Recommendation 1: Continue to recruit from these nearby metropolitan areas which offer shorter commute times and lower cost of living. Reevaluate calculation of pay. ... 41

3.1.2 Recommendation 2: Increasing Management Visibility and Engagement... 42

3.1.3 Recommendation 3: Invest in Knowledge-sharing and Process Improvement A cro ss S ites ... 53

3.2 Focus and Sim plify... 45

3.2.1 Recommendation 1: Review Logistics Scheduling, Implement New Route Tracking, and Review SPT Shift Hours... 46

3.2.2 Recommendation 2: Continue to Invest in Client Solutions to Simplify Requisition Subm ission M ethods... 46

3.3 Standardize and Empower... 48

3.3.1 Recommendation 1: Create empowerment by forming Continuous Improvement and other C om m ittees... 49

3.3.3 Recommendation: Create a system of management oversight based on performance and tenure with the company... 52

3.4 C ross-train ... 53

3.4.2 Recommendation: Create opportunity to learn and connect with Journey beyond Specimen Management through "Day in the Life" and mentorship programs that cross organizational boundaries... 55

3.5.2 Recommendation: Revise methods for tracking overtime to focus on variability,

rather than average, overtim e ... 58

3.5.3 Recommendation: Revise advertised job description, seek feeder programs... 43

3.6 Taking the High Road to the Good Jobs Strategy: Conclusion... 60

4 Solar Implementation Analysis ... 62

4.1 Utility Consumption and Additional Factors for Consideration at Journey... 64

4.2 M arginal Em issions Rates... 66

4.3 NREL SAM Model to Assess Solar Potential... 68

4.5 Financial Model to Assess Economic Viability ... 75

4.5.1 Financial D iscussion ... 77

4.6.1 Summary of Sensitivity Analysis... 82

4.7 Sum m ary of Findings ... 83

4.8 Future Investigation A reas ... 86

Appendix A: Employee Turnover at Selected Journey Locations... 87

Appendix B: Frontline Idea Board... 88

Appendix C: Tests-in-question Arranged by Client ... 89

Appendix D: Base-case and reduced-case first-year turnover, and high-case >3-year turnover.. 90

Appendix E: Specimen Processing Technician Job Posting (from Ziprecruiter.com) ... 93

Specimen Technician I -Westborough, MA -req6327... 93

Journey Health Incorporated Westborough, MA ... 93

Journey H ealth Incorporated ... 94

Appendix F: Employee Survey Results from Westborough... 95

Appendix G: Employee survey results from Tampa... 98

Appendix H: Clarification on the SMART program ... 101

Appendix I: Energy Information Administration Data Tables ... 102

Appendix J: ISO New England Raw Real-time Electricity Generation Fuel Source Data Sample Table (full data set excluded for length)... 103

Appendix K: ISO New England Existing and Coming Natural Gas Plant Capacity... 104

Appendix L: NREL SAM Three-Dimensional Model Solar Output Results (with shading)... 105

Appendix M: NREL SAM Three Dimensional Solar Outputs (without shading)... 106

Appendix N: Series versus Parallel Solar Array... 107

A ppendix 0 : Financial Calculations... 108

Appendix P : NREL SAM Solar Output Estimates Compared with Precipitation Data ... 109

List of Figures

Figure 1.1 Em ployee Hierarchy of N eeds ... 14

Figure 2.1: What is the most satisfying part about your job? Choose all that apply...20

Figure 2.2: What is the most frustrating part of your job?... 21

Figure 2.3: What is the most satisfying part of yourjob? Choose all that apply. ... 21

Figure 2.4: What is the most frustrating part of your job? Choose all that apply ... 21

Figure 2.5: Material Flow in Specimen Management... 26

Figure 3.1: Organizational Structures Observed... 51

Figure 3.2: M idnight H uddle Structures ... 52

Figure 4.1: NREL Levelized Cost of Electricity (LCOE) Benchmarks... 63

Figure 4.2: Annual Average Solar Irradiance of the United States... 63

Figure 4.4: Aerial View of Journey Health Westborough Property...69

Figure 4.6: Aerial View of Three-Dimensional Site Model in NREL SAM ... 71

Figure 4.7: Side View of Three-Dimensional Site Conceptual Model ... 72

Figure 4.8: Conceptual Shading M odel ... 73

Figure 4.9: Areas Al and A2, 1400h (left) and 1800h (right), August 16, 2017...75

Figure 4.10: Conceptual Model of SMART Program Block System from Electricity Rates ... 76

Figure 4.11: NREL SAM estimated system output with MA DCR precipitation data ... 80

List of Tables

Table 4.1: Site-Specific Conditions for Solar Viability... 68 Table 4.2: Financial assessment with High/Low installation costs and energy output scenarios788 Table 4.3: Upper- and lower-bound output scenarios... 83 Table 4.4: Journey Health Concerns about Onsite Solar Generation ... 855

Chapter 1

Introduction and Opportunity Statement

1.1 General Opportunity Statement

Behind every test result, there is a value chain that extends from extracting the specimen required to run the test, bringing the specimen to the laboratory, receiving it at the laboratory, running the required tests, and returning results to patients and healthcare providers so that they can make informed decisions about their health. Journey Health is a laboratory the provides services in all aspects of this value chain. The company seeks continued improvement in all aspects of its operations. This research focuses on reducing first-year turnover rates in Specimen Management, the portion of the value chain that accepts the specimens into the laboratory and confirms that they are in the appropriate condition to have testing run.

Prior to conducting my research, it was critical to understand Journey's interest in reducing first-year turnover, and why it has selected that metric to determine successful

workforce management. In highly standardized work environments, it is possible that high rates of turnover may not have a significant impact on company operations.

Nationwide, Specimen Management averages 50% turnover among first-year Specimen Processing Technicians (SPTs). That is, half of new hires will leave before finishing their first year on the job. This number varies, with some locations closer to 30% first year turnover and others exceeding 100% (meaning every SPT hired will leave within the first-year on the job, necessitating replacement) (Appendix A). Employee turnover is a significant drain on resources at Journey, costing an estimated $7,500 per turn and causing a loss of productivity while

replacement hires ramp up to full performance. A new SPT requires up to nine months to be trained and reach full performance, with Journey estimating processing throughput of an SPT with three months on the job only 66% that of an SPT with nine months on the job. Trainers at Journey spend the majority of their time on training new employees, time that could be invested in uptraining employees for more advanced tasks, including progressing from Level I to Level II or III, as well as evaluating retraining needs and collaborating with SPTs for new hire

Journey hires about 300 SPTs per year (based on Journey's internal Good Jobs Strategy dashboard). Half of those will resign, resulting in a total cost of $1.1 M. Specimen Processing Technicians may resign for a plethora of reasons, including hours, pay, job fit, and competing opportunities.

I evaluated a roster of Journey employees and found that SPTs who are with the company for more than three years are far more likely to remain with the company over a decade or potentially the duration of their careers. The vast majority of turnover occurs during the first two years of employment. The first part of this thesis seeks to further Journey's commitment to be a top employer and provide its employees with fulfilling jobs while minimizing operating costs. Specifically, it assesses the key drivers of Specimen Processing Technician dissatisfaction and turnover and develops a plan that leverages the Good Jobs Strategy to alleviate them. Ultimately, Journey would like to reduce first-year turnover and encourage employees to build their careers with the company. The scope of the project includes all of Specimen Management at Journey, which includes the Specimen Management Manager, Supervisor, Group Leads, Problem Resolution Coordinators, Trainers, and Specimen Processing Technicians. Processes evaluated and recommendations made include changes to Specimen Management operations, but do not extend to broader changes such as revisions to Journey's overall organizational structure. At the end of this paper, I recommend expanding alignment of the Good Jobs Strategy across frontline operations to reduce the occurrence of competing interests, e.g. between Logistics and Specimen Management, but I do not conduct an in-depth evaluation of structural changes within the Logistics organization itself, such as adjustments to Logistics' routes or schedule.

The second part of this thesis seeks to assess the potential for onsite solar to provide financial benefits to Journey by reducing utility costs. Journey's laboratories are typically sited about 30 to 45

minutes outside of dense population centers. The labs are a mix of leased and owned properties, typically with a large central building and an adjacent surface parking with sufficient parking for a few hundred cars. These lots are uncovered and usually shaped as squares or rectangles. Vehicles on Journey property include employee-owned personal cars as well as Journey-owned small SUVs that are used by the Logistics group without unusual height requirements, offering the potential that a structure could be built over the parking area. Furthermore, solar energy has the potential to further Journey's corporate citizenship goals, which view environmental responsibility as aligned with the

vision of contributing to the health and wellbeing of people everywhere. Journey's formalized environmental program is called GreenJourney.

Where I evaluate the technical and economic feasibility of on-site solar generation at Journey's Westborough, facility, I assess the patterns of Journey's electricity consumption, but do not conduct a quantitative assessment of the primary sources of electricity consumption. Rather, the analysis focuses on the viability of a solar farm itself, which could be thought of as essentially separate from the Journey facility and operations. However, I take into consideration the required layout of solar panels given the current usage of the property. In addition, I provide a high-level summary of potential choices that could lead to reduced electricity consumption.

1.2 Background

Journey Health

Journey Health is a provider of diagnostic testing. The company seeks continuous improvement to all parts of its business, particularly quality and turnaround time. For the purposes of the laboratory, quality refers to accuracy of results, and turnaround time represents the speed at which results reach patients. Requisitions, or requests for a set of diagnostic tests, can reach Journey from clients through two channels. Clients may draw their own specimens from patients or refer the patients to Journey-owned Patient Service Centers where Journey employees will draw specimens from patients and send them to a Journey laboratory.

Journey has two types of laboratory setups, standard and non-standard. A standard laboratory features a conveyor belt for bringing bins containing the requisitions to the SPTs and can utilize Journey's proprietary software system for managing requisitions. Clients for a

standard location may still opt to use non-standard processes. A nonstandard laboratory lacks the conveyor belt system and uses older versions of test codes that are proprietary to the location.

The combined order that a medical provider has given a patient for a set of tests plus the specimens associated with those tests is defined as a "requisition." One requisition can range from a single test that requires a single sample, e.g. a single vial of blood, to ny tests that require larger volumes of the sample or more than one type of sample, e.g. a vial of blood and a cup of urine.

The Good Jobs Strategy

The Good Jobs Strategy was developed by Professor Zeynep Ton based on her research into select high-performance organizations where employee satisfaction ranked highly despite prevailing industry trends. She found that these companies outperformed the competition by making putting investment in their employees at the forefront of their values. They then designed their frontline operations around four key pillars: standardize and empower, cross-train, focus and simplify, and operate with slack.

1) Standardize and Empower: Good Jobs Strategy companies standardize routine

processes while empowering their employees to improve those processes and respond to customer needs.

2) Cross-Train: Rather than keeping employees in silos, cross-training allows Good Jobs Strategy employers greater workforce flexibility to meet variable demands.

3) Focus and Simplify: Good Jobs Strategy companies make strategic trade-offs to maintain their focus on the problems they solve for their customers and simplify operations in ways that maximize value for their customers while improving employee productivity and motivation.

4) Operate with Slack: Staffing with more hours of labor available than expected workload for peak customer demand enables Good Jobs Strategy companies to give employees time to perform their tasks as well as engage in continuous improvement, while reducing stress for employees.

Importantly, the Good Jobs Strategy is a journey, not a destination. Companies will always encounter new employees with new personalities, new motivations, and new preferences. But the value of the Good Jobs Strategy framework is in creating a culture in which an

organization is designed to be able to respond to these changes because the employees who make up all levels of that organization are empowered to take control of their careers.

1.2.1 Journey Good Jobs Strategy Precedent: The Call Centers

In July of 2015, Journey Health, implemented the Good Jobs Strategy in its National Operating Centers (NOC) in response to significant rates of turnover among first-year employees and to seek continued improvements in the level of quality it was able to provide its clients and patients. Most importantly, the company laid a foundation of investing in its people to establish

stability in the workplace, which had been suffering with high levels of turnover and absenteeism. First, Journey raised starting wages for call center reps by $1/hour while

introducing step-based pay, meaning that wages would increase at set periods of time within the first year of hiring. HR also created a new customer service career path for the reps to give them a clear road map of their opportunities for growth. By addressing these baseline employee needs, the company was subsequently able to focus on addressing higher-order opportunities to provide rewarding careers to its call center reps. Until the company provided greater resources, including a pay raise, to stem the tide of turnover and absenteeism that negatively impacted the call

centers, work on meaningfulness and self-actualization in the workplace couldn't be executed. In her research, Professor Zeynep Ton represents this relationship in the Employee Hierarchy of Needs, inspired by Abraham Maslow's human psychology research and Frederick Herzberg's theory of motivation.

WORK MEETS HIGHER NEEDS MEANINGFULNESS PERSONAL GROWTH

Work itself and Learning, creativity, significance to customer problem solving

BELONGING ACHIEVEMENT RECOGNITION

Team, pride for working at the Have autonomy, tools, time and High expectations, feedback from company, mutual respect resources to do great work others and job

WORK PROVIDES BASIC NEEDS

As attrition declined, trainers new were able to spend 58% of their time uptraining reps on new job functions, compared to just 20% previously. Most importantly, Journey led the NOCs in implementing the Good Jobs Strategy with energy and enthusiasm, challenging the call reps to rise to the occasion. In fact, while from July of 2015 to the fall of 2016, first-year turnover at the NOC had dropped by half, to 16%, there was a slight increase in attrition shortly following the implementation of new initiatives as part of the Good Jobs Strategy among call reps among reps who were consistently underperforming. From the perspective of customers, only 50% of calls had been answered within one minute, now the rate had increased to 70%. Also, the promotion rate had doubled, and costs had gone down as a result (exact number undisclosed). Journey's commercial team had also demonstrated higher levels of satisfaction with call center

performance. These successes led Journey to create a Good Jobs Strategy initiative across all its frontline operations, including its Patient Service Centers, Logistics, and Specimen Management.

The Good Jobs Strategy that was implemented was organized as follows:

1) Focus and Simplify: Previously, Journey had fielded a significant number of calls asking simply for results and other information, such as locations and hours, that were readily available online. Under the new protocols, clients and patients seeking only their results were redirected to the web to retrieve their results online. Furthermore, the company improved its website to facilitate patients getting to this information without requiring guidance. Critically, this allowed Journey to focus its resources on providing value-added services to its patients rather than redundant services.

2) Standardize and Empower: While efforts were made to continually standardize processes for interactions with customers, Journey made significant efforts to also empower

employees to take control in the workplace. She created a Journey Management System (JMS) team whose main tasks were to work with teams of call center employees, who were organized into pods, specifically around the issues of implementing change. The JMS team was made up of the call center representatives (reps) who stayed on the team for six to nine months after submitting a personal statement to apply. The chosen reps then received continuous improvement training. Workflows and standard operating procedures were strengthened for call center employees to reduce the amount of

would experiment with small changes to work processes and systems, assess the results, and iterate. The JMS team would then work with model pods on their improvements.

Employees were provided a new tool in the form of Frontline Idea Cards (FICs) to engage them in making valuable suggestions and contributions in the workplace in

addition to their fundamental job tasks. An example of a simple suggestion that was promptly implemented was to have clocks on the wall set to the different time zones that Journey serves for easy reference. Another employee-submitted idea was the "Spanish whisper," which notified call center reps before they answered the phone that the caller was a Spanish speaker. As the FIC model has advanced, Journey's NOCs have moved to an electronic FIC system that eases the tracking of ideas from submission through

execution, as well as encourages sharing of ideas and reduction in overlapping efforts. Employees have also received training to empower them to respond appropriately to certain unpredictable situations, such as if a patient calls requesting results due to an urgent situation.

3) Cross-Train: Previously, call center reps were usually assigned exclusively to managing calls from specific regions. As part of the implementation of the Good Jobs Strategy, more reps received training to be able to answer calls in regions other than their home base, which increased workforce planning flexibility by allowing resources to be redeployed according to real-time need. This additional training was supplemented by new systems that could route calls virtually between reps. Under the previous system, reps that had the skills to manage calls from more than a single regions had to physically move between different stations to take those regional calls. In addition to giving Journey the operational flexibility of pooling its employees, this also increased the variety of the work that the reps encountered.

4) Operate with Slack: Supervisors were supposed to meet with call reps monthly to discuss performance and career objectives. Journey noted that supervisors felt that they could never manage to get on top of all their responsibilities and therefore the monthly meetings often fell off their calendars. She brought in a third-party vendor, Coaching Right Now, to give supervisors time management and communication training.

Journey was able to achieve these improvements in the face of stuff regional competition. Kansas City is a popular region for call centers, with employers such as Sprint and AT&T, many of which offer higher hourly wages than Journey. In the words of a Journey Quality Project Manager, "We are seeing some reps leave for competitors in the region as they go through large hiring phases, but then come back because they get tired of the hiring and firing cycle that those competitors do as soon as business goes down. We don't do that to our employees here."

Chapter 2

Research Methodology and Findings

2.1 Site Visits, Employee Interviews, and Data Collection

Journey Health has internal data analytics staff who track key performance indicators it believes are the most relevant for the Good Jobs Strategy. They include absenteeism (unplanned callouts), promotion rate, overtime, compensation rate, and voluntary first-year turnover. These results are updated each month on a centralized corporate wiki page, with the data visualized in Tableau. My primary location of research was the Westborough, MA office, where I conducted interviews and observations across all three shifts on a weekly basis for a six-month period from June through December 2017.

As part of my research, I examined trends across almost two dozen Journey locations in different regions. I identified those that had consistently low turnover rates, consistently high turnover rates, or strong increasing or decreasing trends in turnover. I then conducted telephone interviews with those locations. Based on a discussion with my supervisor, I was able to conduct

in-person site visits at six different Journey locations: Newark, New Jersey, Philadelphia and Pittsburgh, Pennsylvania, Miami and Tampa, Florida, and Kansas City, Kansas. All sites were

selected based on performance of Specimen Management, except for Kansas City. That location was selected because it is one of two central call centers for Journey, and my goal was to observe

and interact with employees who had worked on the first deployment of the Good Jobs Strategy at Journey.

Each site visit lasted for one to two days and consisted of a pre-visit conference call, an in-person meeting with the local Specimen Management manager, and interviews with supervisors and

group leads. Following this, I conducted observations of Specimen Processing Technicians and observed mid-shift huddles. During these observations, I was able to learn the nuances of the job and gain insights into variations that occur across different Journey locations in culture, organizational strategy, and process.

There is the confounding variable during any non-blind observation for bias to occur on the part of the observed party, particularly if they feel they are being audited, known as the Hawthorne Effect. [1] Building rapport is a known method of counteracting this, with the goal of

communicating to the observed parties that the observer is there to learn and facilitate rather than criticize. [2] I made specific active and passive choices with the intent to minimize this bias. Active choices included a personal introduction of my research and the scope of the project, with specific clarification that the goal of the research was to improve their experience on the job and further Journey's mission to be an ideal workplace and further human health. Then I allowed the SPTs a chance to introduce me to their job function and lead the discussion. Passive indicators included dressing casually while on the specimen processing floor, in accordance with the typical style of the specimen processing staff. Because of the associations that individuals have with clipboards and audit, I only brought small pads for note taking while interacting with any of the SPTs.

In some cases, Journey will conduct a brief exit interview with departing employees that consists of a single, informal question, which inquires why the employee is leaving. When the employee includes a stated reason along with the announcement of the resignation, the question is not asked. No formal database or tabulation of these exit surveys exist. The records of exit

interviews that could be retrieved, as well as interviews with Specimen Management Supervisors, suggests that the primary reason SPTs cite for leaving are hours and job fit. One employee who resigned in the past year cited leaving to pursue a rock band

There is often uncertainty about the truthfulness of employee exit interviews. [3] It is possible that an employee would avoid saying anything that they felt could put their future career opportunities in jeopardy. Furthermore, the individual may fear confrontation. To mitigate this, I avoid relying exclusively on exit interviews in my research, including work observations,

interviews with current SPTs, Group Leads, Supervisors, Managers, and other Journey

employees, as well as data from annual Specimen Management employee surveys that Journey conducts.

Interviewing SPTs as they performed their tasks was a potential source of stress for the SPTs. To counteract this, I sought additional opportunities to discuss the nature of the job function with the SPTs outside of the specimen processing floor. SPTs are hourly employees, and a drop in productivity may reflect poorly on the individual. While all managers and supervisors were informed of the observations I was conducting, I still sought to alleviate any

concern on the part of the SPT that they might be penalized if their production dipped slightly as I observed them. To do this, I also arranged for lunch meetings that occurred at lam, the typical lunch break time for the SPTs, to interview them and receive their feedback without distracting them from their work. Journey kindly allowed me to expense sandwiches to bring to this

midnight lunches for the SPTs. I conducted one midnight lunch in New Jersey, and two midnight lunches in Westborough, Massachusetts, one during the first half of my internship and the second near the end of my tenure.

Where I could not conduct in-person site visits, I held telephone interviews with Specimen Management managers including locations in southern California, the Midwest, the Mid-Atlantic,

and the Gulf Coast. Managers frequently cited Journey's initiatives to roll out a standard welcome packet and training materials as facilitating the onboarding of new SPTs in a consistent, timely manner.

Following the end of my research period, I conducted an anonymous survey of five basic questions designed to assess how SPTs felt about their job. I did not conduct the survey earlier in my research due to a concern about survey and continuous improvement fatigue. Journey provides annual employee surveys that address topics such as compensation, ethics, management, and

treatment. Figures 2.1 through 2.4 summarize the results of the survey. The full results and questions are in Appendices F and G.

Westborough 110.00% 00 00% 90.00% 80.00% 70.00% 60,00% 90.00% 40.00% 30.00% 20.00% -10.00%

L0s tha a y..r y-3y- 3-0 S. Y

F Industry W Pay Hourustch sa y Location p Jo a Fu abtion u P y j C I wsd at a Oatpr

80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%

Less than a year 1-3 years 3-5 years 5+ years

E Industry E Pay U Hours/Schedule E Location N Job Function M People I work with N Other

Figure 2.2: What is the most

frustrating

Less than I year I to 3 years 3 to 5 years 5+ years

0 Industry U Pay E Hours/Schedule N Location U Job Function U People I work with U Other

Figure 2.3: What is the most satisfying part ofyour job? Choose all that apply.

MO.o% 70.00% 60.00% 0.00% 40.00% 3000% 20.00% 10.00% 0.00%

Less than I yeaw to 3 years 3tof5yeara 5 yer$

U Industry E Pay M Hours/Schedule 0 Location N Job Function 0 People I work with M Other

McGregor argues that alignment with the company objectives is critical for enabling Theory Y management. 100% of Westborough SPTs surveyed agreed that they believed their role was important for the patient, while over 90% of SPTs surveyed in Tampa agreed. However, during individual interviews SPTs in different locations indicated a sense of disconnect from the patient. To this end, Journey has rolled out a short documentary video that highlights one of its patients and how the services that Journey provided enabled this patient to get the care they needed. Journey intended for frontline managers to cascade the video to their employees. Specimen Processing Supervisors that I interviewed had not rolled out the video, and were uncertain how they would do so, because SPTs do not have internet access at their workstations. One opportunity would be to display the video on the LCD monitors that hang from the walls on the Specimen Management floor of each Journey laboratory. This could occur during the recurring midnight huddles to facilitate discussion, feedback, or questions by SPTs.

Westborough and Tampa had similar survey results for pay satisfaction, with pay

increasingly cited as a source of frustration as SPTs progress through their careers (Figures 1.2-1.5 and Appendices F and G). The progression from Level I to III can take three to five years, after which a limited number of SPTs may progress to Trainer or Supervisor roles. Correspondingly, pay increases level off, and employees with decades of experience will not make more than employees with about 5-7 years on the job. Because the portion of SPTs with this tenure at Journey is low, turnover from this group is diminished in impact relative to first-year turnover at Journey. As the company seeks to retain employees beyond their first few years with Journey, it is likely that the relative portion of turnover driven by resignations from employees with over three years with the company will increase. However, I estimated that a scenario in which 90% turnover across employees with over three years with Journey and 10% turnover among employees with less than three years would still result in lower recruiting, hiring, and training costs overall (Appendix D).

Following the preliminary results of my assessment, Journey Health began incorporating feedback into management of the SPTs.

2.1.1 Summary of Relevant Specimen Management Organizational Structure and Career Path

Specimen Management Roles are divided as follows:

" Level I SPT: Responsible for general support functions with the Specimen Processing Department. Functions performed may include but are not limited to data entry of test orders, presort, pickup and delivery of processed specimens to the laboratory,

centrifugation and aliquoting.

" Level II SPT: Responsible for knowing all functions of Level I SPT as well as more complex processing that may include A Station (manual entry), Frozen specimens, CPU (including hospitals), and microbiological samples.

* Level III SPT: Responsible for knowing all functions of Level II SPTs as well as possibly handling client communications, internal training, and problem solving related to special accounts and compliance. Level III SPTs will be more involved in complex processing including but not limited to: Microbiology processing, Frozen splits, Sen outs, Cytology processing, irreplaceable specimens, and special handling including allergies, serial, and pediatric specimens.

" Group Lead: Assists the department supervisors by performing various combinations of the following activities: schedule coordination, general supervision of all SP Technicians, providing input to supervisors for performance review and disciplinary action. The Group Lead typically leads 8 - 12 employees, is involved in process and compliance audits and may be responsible for assisting in troubleshooting and problem resolution, monitoring supplies and ordering more supplies when necessary. The Group Lead also may perform cross-training on SPTs.

" Problem Resolution Coordinator: Assists department management and is responsible for conducting audits of all Specimen Processing processes to ensure the department

maintains high standards in quality and compliance. Audits that could be performed by the Advanced Problem Resolution Coordinator may include Department and individual compliance audits, error tracking, etc. The PR Coordinator also functions proactively in a problem resolution capacity and works to identify and solve issues in processing and testing laboratory specimens. Collaborates with various departments including, but not

limited to Specimen Processing, Referral Testing, and Technical departments to research and resolve issues, expedite specimen testing and result reporting.

* Trainer: Responsible for training all Specimen Preparation Technicians in all phases of Specimen Processing. The trainer is responsible for providing input to supervisors

regarding the Specimen Preparation Technician's progress and performance and may also conduct process and compliance audits as needed. The SP Trainer is responsible for training of new hires and existing employees on an on-going basis ensuring they can learn critical skills needed for career progression.

" Supervisor: Supervises functions within Specimen Processing department, which may include one or more of the following: Specimen Processing, Test in Question/Problem Resolution, Imaging/Microfilming. Responsible for overseeing the following activities, daily operations of Specimen Processing, all compliance training, training of personnel, monitoring Quality of the department(s), monitor and improve productivity. Ensure maintenance of a safe, ergonomically sound, professional environment. Know and understand all functions of the department. Typical direct reports 20-25.

" Specimen Management Manager: Responsible for managing all aspects of Specimen Management, which includes managing staffing requirements and conveying needs to Journey management and Cielo for third party recruiting, communicating and coordinating with other departments at Journey, interviewing of new candidates with the Supervisors. Also responsible for managing the cytology department.

After nine months, if attendance and performance have both been strong, Level I SPTs can to advance to Level II. After another year to two years, Level II SPTs may advance to Level III. Pay raises are determined at annual performance reviews and when SPTs are promoted to more advanced

levels.

Interviews with the Specimen Management Manager indicated that annual performance review for career planning and raise is primarily based on productivity of SPTs and finish times for the shift, total headcount of fulltime employees (which reflects level of expected effort to manage by the Specimen Management Manager), and quality, which includes quantity and magnitude of errors

in accessioning. Management one level up indicated that reviews will also include SPT satisfaction and career growth. Finish time in this case is defined as the time at which all third-shift requisitions

have been accessioned, with a target close time of 6am, but a final shift close by 8am., with remaining requisitions to be accessioned by first-shift. Quality is defined by errors, which include missing/lost samples, wrong names on requisitions, and test code errors. Additionally, the Specimen Management manager will address potential HR issues with employees, liaise with and respond to requests from internal clients in other parts of the organization, such as the laboratory or customer

solutions, assist in the onboarding of new clients to Journey, take additional trainings for new corporate procedures, enhancement to Journey's proprietary software system's functions, and other initiatives, and review staffing needs and career development. In Westborough, the Specimen Management Manager began her career as an SPT, and through her passion and dedication to serving tens of thousands of patients each night rose through the ranks to her current position.

2.1.2 Operational Overview of Specimen Management

Journey receives requisitions in two ways. Patients with testing orders from their medical provider may visit a Journey-operated Patient Services Center (PSC) to have the necessary specimens drawn and requisition created. All Journey PSCs run on a standardized system

whereby an initial requisition will be created electronically at the PSC and submitted to the lab in advance of the specimen. When a requisition is submitted through a PSC, no additional

accessioning is required at the laboratory and the specimen can be directly delivered for testing with handling by an SPT. The client may have in-house services for drawing specimens. These clients may or may not use Journey's electronic submission system, as clients submitting requisitions with their own proprietary paper forms that Specimen Processing Technicians at Journey will later enter. In either case, Journey-operated Logistics collects requisitions from clients and PSCs and delivers them either to aggregation points or to the laboratories. These pickups occur primarily in the evening and occur during the day only for urgent requisitions.

Once Logistics has delivered the requisition to the laboratory, Specimen Management accessions the requisition, or accepts it into the lab. While Logistics' drivers will do some sorting of the requisitions during pickup, sorters will again sort the requisitions again to ensure

separation of manual and electronic requisitions. These sorted requisitions will then be

distributed to dedicated SPTs whose role is either to accession manual or electronic requisitions (Figure 2.1).

Patient Service Center

or Client draws

specimen from patient and creates

requisition Logistics picks up sample and aggregates at a delivery node or delivers directly to Sorters in Specimen

Management sort the requisitions

I1

Type?

PSC

Sends electronic

requisition through Auto Accessioned

Electronic copy received?

E station E sttionentry Refer for manual

No

Errors? _{Finish accessioning}

A station

Errors/

Questions?

Refer to group leads B station

No

Figure 2.5: Material Flow in Specimen Management

yCd

4, C);.

N

2.1.3 Specimen Processing Technician Job Description

Because accessioning is at most a two-step process, Journey utilizes a form of batch flow. Requisitions are divided upon delivery into bins of approximately equal requisition count, and the bins are weighed to approximate the requisition count. This is intended to ensure that each bin represents approximately the same level of work. At a standard laboratory, these bins are placed on a smart conveyor belt, which will transfer them to the SPTs who sit at stations adjacent

to the belt. The belt is controlled by the actions of the SPT, and it can detect when an SPT has completed their previous bin and subsequently deliver a new bin. At a nonstandard laboratory, these bins are aggregated on carts where SPTs can leave their stations to retrieve once ready.

Once the SPT has retrieved a bin of requisitions to accession, they will execute the following process for an electronic requisition:

1) Tear off the seal to the plastic bag along the perforated line and dispose of the piece in a bin located at their station.

2) Remove the printed requisition and specimens from the bag. Scan the barcode on the requisition to bring up the corresponding electronic order.

3) Confirm that the name on the paper and electronic orders match. If they do not match, set aside the requisition to be reviewed.

4) If the names match, the SPT will then confirm that all the tests listed on the paper form appear on the electronic form. If they do not, the SPT will add the tests in the system. At this step, the SPT will also confirm that the specimen provided is also sufficient in type and volume. Journey's proprietary software system can provide such information if the SPT is not aware.

5) Once the SPT has completed the accession, a printer at their station will print out a barcode to apply to each of the specimens in the requisition as well as on the paper test order. It is important for the SPT to note that the barcodes are unique to their application, so the correct barcode must be applied to each specimen and the paper test order.

6) The SPT then affixes the appropriate barcode to each specimen and places it on a

conveyor belt that drops the specimens in a bucket. The SPT files the paper test order in a folder which will later be collected and aggregated for record-keeping.

7) These buckets of accessions specimens are then handled by Technical Operations (Tech Ops), which distributes the specimens to the appropriate areas of the laboratory.

Starting in May of 2017, Journey standardized the SPT workstations. Prior to that, workstations were generally comparable but had inconsistencies in the arrangement of storage bins, folders, printers, and other details.

Specimen Management is divided into three shifts: first, second, and third. To prevent gaps in operations, there is a slight overlap between the shifts. A typical shift is 8 hours, with 30 minutes for lunch and two 15-minute breaks. First shift spans 6am to 4pm, second shift spans 2pm to midnight, and third shift spans 10pm to 8am. Note that length of a full shift is eight hours, not ten, but that the shifts have overlap because of varying start times of SPTs within the shift, as well as to minimize any idle time in Specimen Management. At most Journey locations, Specimen Management operates entirely during the third shift, as requisitions that are retrieved during the day and then delivered to the laboratory in the evening for overnight accessioning. This allows the specimens to be tested the following day. A few locations, Westborough included, have limited daytime shifts. The Westborough location has roughly 20% of its requisitions accessioned during the daytime due to agreements with local hospitals. Correspondingly, while SPTs sit in the same location each night in most locations, at the Westborough location it is possible that the SPT will be in a different seat because of overlap across the shifts. In locations where SPTs have the same station each night, some SPTs will personalize their station with photographs of their family or other items. SPTs with whom I spoke did not indicate significant concern over this.

Specimens are drawn from patients during daytime hours, a practice that is recognizable to most individuals who have previously had any blood work or other diagnostic testing. Journey's Logistics will then retrieve these specimens during the late afternoon or evening and deliver them to the laboratory for accessioning overnight. This allows the tests to be run on the following day. Previous studies to assess the possibility of increasing the service level of Logistics to retrieve specimens in an ongoing basis to allow for more daytime operations in Specimen Management have found that this would increase Logistics' costs by 72% because of the magnitude of increase in Logistical redundancy, in cases where Logistics must now make more than one stops at the same client. [4] At the same time, this would only move a fraction of overnight staff to the daytime shift. Importantly, while the total headcount of first- and second-shift SPTs at Westborough is only a

fraction of third shift, with about 15 SPTs, first-year voluntary turnover rates are about the same based on Journey data sources. We must note here that because hiring during first- and second-shift is around 3-4 individuals per year, a single resignation has a significant impact on the calculated percentage of turnover. Ultimately, there is insufficient potential benefit demonstrated from a shift to a daytime-oriented schedule to justify the increased operational costs.

Expectations of the SPTs while on the job include high rates of throughput (often hundreds of requisitions in an evening), minimal conversation with peers, and notifying supervisors when taking lunch or a break, as well as when leaving the work area to use the restrooms or get a drink.

2.1.4 Common Challenges for Specimen Processing Technicians

In a scenario in which all clients sent their patients to one of Journey's Patient Service Centers, which are standardized and require no additional input at the laboratory by the Specimen Processing Technician, the SPT role would cease to exist. However, this is not the reality, and because a significant portion of clients prefer using their own means to submit

requisitions, which may include unique containers and requisition forms, the SPT role is required to manage this variability. Thus, the SPT plays a key role in the satisfaction of the client, despite there being no direct interactions between SPT and client in the present organizational structure. Each Journey location may accession tens of thousands of requisitions per evening, representing thousands of different clients. There are many potential errors that SPTs must detect.

" Test-in-Question (TIQ): A test-in-question occurs when there is uncertainty of the type of test that is being requested. Each test that Journey runs is given an electronic code, and these codes are typically written on the paper requisition along with the name of the test. When the client does not include the code on the requisition, the SPT will look up the code using Journey's standardized software system. If the test cannot be found, this results in a TIQ.

" Requisition doesn't cross: Most clients are set up to use Journey's electronic submittal system. Occasionally, the submittal will not go through ("cross"), and the Specimen Processing Technician will be responsible for manually entering the tests that the lab is to run on the specimen.

" Specimen Errors: These may include Quantity Not Sufficient (QNS), incorrect specimen for the test (e.g. blood versus urine), or incorrect condition of sample (e.g. total blood versus serum-only, liquid versus frozen, room temperature versus chilled)

" Handwriting: Some SPTs cited handwriting on Journey clients' paper forms as the most significant challenge or source of uncertainty that they face.

" Wrong Name: Each requisition comes in a plastic zipper bag with a tear-off top. The bag contains the specimen(s) as well as a paper printout of the requisition form. Occasionally, the name on the form will not match the name on the specimens, which may be either a simple data-entry error or more significantly that specimens have been switched at the client.

SPTs can often manage minor errors such as missing test codes on their own, either knowing the test code from memory or looking it up on the Journey's proprietary software system. For more significant problems, the SPT can either set aside the requisition and wait for Problem Resolution Coordinators to aggregate problem requisitions, or in more urgent cases immediately seek PRC assistance. In that case, the SPT will either turn on a yellow light above their station (the Andon cord) or leave their station to go to the PRC.

2.2 Tracking Turnover

Journey tracks first-year, voluntary turnover on a rolling twelve-month basis. Because SPTs are not hired on specific dates, but on an as-needed basis, it is possible that SPTs that have been hired within the past twelve months may still resign before their first anniversary with the company.

Similarly, SPTs who were hired outside of the past twelve months may have still resigned within that twelve-month period within the first twelve months of their employment, which result in an inflated turnover rate if the denominator were to consist only of SPTs hired within the past twelve months.

To adjust for this source of variability, the denominator Journey uses when calculating the proportion of first-year employees that have voluntarily terminated employment is an average of the total headcount of first-year employees at the start of the twelve-month period and the end of the twelve-month period. In the extreme example, consider a situation in which all hiring within the past twelve months occurred within the past six months, so that all our first-year employees have six months on the job. If all are still employed, this results in a first-year turnover rate of 0%. However,

these individuals may still resign within the next six months, during their first year of employment. Consequently, I searched for long-term trends in first-year voluntary turnover rather than specific data points at any given month that showed a spike or drop in turnover.

Declining trends in first-year turnover were observed in two Pennsylvania locations and Kansas (Appendix A). Houston and Tampa were observed to have consistently lower-than-average first-year turnover. Dallas, Westborough, and Newark were seen to have generally increasing trends in turnover. Note that no laboratory had first-year turnover rates consistently below 30%. Data was not available prior to December 2016, for studying longer-term trends.

2.3 Causes of Turnover

In my interviews with SPTs and through my surveys, I find three key areas of potential drivers of employee dissatisfaction and turnover. I find that drivers of employee turnover can vary in different locations. Journey employees face turnover drivers that relate to key aspects of the employee pyramid of needs.

1) Relationships between SPTs and their peers and SPTs with management

A sense of belonging is a key aspect of the employee pyramid of needs (Figure 1.1). This sense of belonging is derived from a connection to peers as well as the mission of the organization. In Westborough, "People I work with" was a key driver of satisfaction among employees with 3-5 years on the job, and also cited by SPTs with greater than five years at Journey. Conversely, "People I work with" was commonly cited as a source of frustration by employees with under a year and 1-3 years with Journey, but not cited by any SPTs with 3-5 years with the company, and cited by a few SPTs with greater than five years with Journey.

These results imply that a lack of strong relationships with colleagues is a driver of early-career turnover, and that those who are frustrated by or isolated from their colleagues may end up leaving Journey, while those who stay are those who have built strong relationships with their colleagues.

These data support the results of my SPT interviews, which often found that SPTs either did not know their colleagues or often felt actively excluded by colleagues, citing

issues such as lack of respect for the job and for one another. Others felt that their peers tended to stay in tight-knit groups formed out of SPTs who had all been referred to the job by

the same person. Examples of this that I discovered in my research include employees not knowing the names of their colleagues and rarely interacting with Group Leads or mentors, as well as observing in frustration colleagues making posts on facebook that showed the colleague enjoying a night out while having called in sick to work. SPTs that I interviewed indicated that they did not feel comfortable discussing with their peers the impact of these unplanned absences. Some SPTs also indicated a lack of confidence in the skills of newer hires or their peers in general, questioning whether their peers understood the critical nature of ensuring an error-free output.

I also identified signs of weak trust between Supervisors and SPTs. For example, SPTs are presently expected to notify leadership if they are leaving their workstations to take a quick break or use the restroom. For SPTs, particularly those with significant tenure at Journey, such a requirement may be demeaning. It is also time-consuming. The intelligent conveyor belt system means that requisitions will not be delivered to an SPT's workstation if they are not at their seat. To understand the drivers of the current state of trust, I interviewed Human Resources representatives, Specimen Management Managers and Supervisors about this requirement, and received several comments that eliminating this requirement would lead to SPTs wandering away from their stations and not performing their tasks. In the past, one Supervisor indicated they had found SPTs engaged in inappropriate activity in a

conference room.

There were additional opportunities to improve relations between senior management and SPTs. It was observed during tours of the Specimen Management area that often senior management will bring in guests to observe the facilities without engaging the employees. This includes leading the guests within speaking range of the SPTs but describing the SPTs and their job tasks as though the SPTs aren't there. It is possible that senior managers simply do not wish to disturb the SPTs, but the implication may be that there can be absolutely no disruption in productivity and that senior management has no interest in engaging with frontline employees. While Journey holds quarterly town hall meetings, and a separate town hall meeting for each shift, interest and attendance by SPTs is low, with Supervisors

indicating to me that it can be difficult to convince SPTs to attend.

Meaningfulness, as conveyed by Journey management, is a critical higher-order component of the pyramid of needs. It is another challenge SPTs face. In addition to

frustration at their relationships with peers, SPTs made dozens of independent comments in response to my surveys and during my interviews about feeling stressed out, undervalued, and under pressure from management, often to the point of being overcapacity. Almost 100% of SPTs that I surveyed believed that their job was important for the patient. Despite this, I received dozens of comments from employees that pertained to feeling a lack of connection to the patient as well as a sense that the long hours that they worked were only to meet

production targets, not to serve specific patient needs that carried personal meaning. One way that Journey's call centers have started to address this is by including in new employee

training a video that explores the impact that receiving results from Journey had on a patient's life-changing medical treatment decisions. A similar video has been rolled out company-wide, but Specimen Management Supervisors indicated to me that they had not seen the note from executive management to cascade and discuss the video with all staff. In addition, Supervisors questioned how they would display the video for the SPTs.

2) Hours and Job Fit

A review of exit interviews indicated that some employees stated that they left the SPT role because of finding a job with daytime hours or a job with better fit. Furthermore,

Specimen Management Managers and Supervisors indicated a long-held belief that the third shift would inherently result in high turnover rates. Journey has increased hiring targets for college graduates to 25% of new SPTs. However, Specimen Management Managers and Supervisors felt that recruiting new hires with higher degrees would result in high turnover as those employees left for jobs that required a more direct application of their academic

training.

While these two beliefs have grounding in reality, I find in my interviews and surveys that the reality is more nuanced. Several SPTs that I interviewed indicated that they had in fact sought out jobs with third shift hours. One reason that came up from at least six SPTs was that they had young children at home and preferred to sleep during the day while the children were at school and work at night while the children were home sleeping, a finding I confirmed with Supervisors is a common trend. Where frustration continually arose was in situations of repeated mandatory overtime requirements, where SPTs were left feeling overworked and undervalued.