Author Archives: David Novis

Leading the CAP: Views from the Top

CAPconnect  November, 2017

Leading the CAP: Views from the Top
David A. Novis, MD FCAP

The Presidency is the highest office a Fellow can achieve in the CAP. In their campaigns, candidates itemize on their websites and in presentations to the CAP House of Delegates and state Pathology society meetings, qualifications they believe render them suited to serve in this position, and offer their opinions at to what directions they believe the CAP should pursue.  But what happens at the end of their presidency?  I am not aware that past presidents routinely provide their constituents post mortem reports of their services. These reflections might provide Fellows an appreciation of the assets and liabilities of the CAP, which has the second highest revenue of any medical society—second only to the American Medical Association (AMA).

To provide insights that might help Fellows frame their expectations of future presidents, and of their society’s governance system, I recently interviewed all living past CAP presidents (Table 1, see below), and asked them ten questions (Table 2, see below). I informed interviewees that I would not quote them. To be clear, it was not my intention to judge, evaluate, or validate their responses, or to provide objective views of what they did or did not accomplish during their terms of office. I was only interested in their impressions and perceptions of both the office of the Presidency and the system of governance over which they presided. All the past presidents listed in Table 1 participated in the interviews. Interviewees were given the opportunity to comment on the final draft of this manuscript before I submitted it for publication.

Below are some of my initial findings from these interviews; the remainder of my findings will be shared in part two of this blog, to be published next week. What Motivated Presidents to Seek office?

Presidents were motivated by their desire to serve the CAP, their Fellow peers, and their patients, all of whom provided meaning to their professional lives. They believed that of all the candidates who might have been willing to hold office at the time, they had the most experience and understanding of this highly complex organization, and were the best qualified to confront issues vexing the CAP. Only one President claimed to have had no designs on the office and ran only at the request of his peers.

All Presidents had served the CAP for decades—on the Board of Governors, committees, councils, House of Delegates, accreditation inspection teams—and possessed considerable knowledge of the CAP and how it works. They had developed close relationships with pathologists who had also served and/or were serving in CAP leadership roles and were thus in positions to advance their candidacies. Some Presidents planned their candidacies years in advance, others came to that decision relatively late in their careers. Regardless of the timing, for the years leading up to and during their candidacies, presidents traveled extensively, stumping at state pathology and other professional society meetings in efforts to build their networks, explain their candidacies, and expand their exposures.

How Effective were Presidents in Pursuing Their Goals?

All Presidents had specific goals they wanted to accomplish, some of which they conceived well in advance of their terms, others formulated after they were elected. Some Presidents arrived at their agendas in confines of personal vision, others in the plurality of what they believed to be general member sentiment. In an effort to understand the needs of their constituents, some Presidents traveled the country exhaustively, meticulously canvassing pathologists’ opinions, needs, and anxieties.

Most Presidents believed they were successful in achieving their goals and were able to point to evidence of those successes.  For others, achievements were less tangible and open to interpretation. Some Presidents claimed that they were unable to realize their visions, at least not during their terms.  Table 3 (see below) lists in no particular order, the outcomes of the goals that Presidents had in mind to achieve.

What Influenced Success? Failure?

All Presidents attributed their successes to the support they received from their peers serving on the Board of Governors, councils, committees, and in state Pathology societies. Most often, they cited their immediate predecessors as being the most supportive of their agendas. It also worked the other way. Peers whose biases ran counter to Presidential initiatives provided some Presidents considerable resistance to achieving their goals.

Almost all Presidents agreed that other than their member peers, the CAP staff was the greatest asset that the CAP provided them, and that it would have been impossible for them to achieve their goals without the assistance of this extraordinary talent.

In addition to hearing their self-reflections on successes and failures, I wanted to dig deeper into their views on the role of the CAP President, the CAP governance structure, and working with the Board of Members. Below are my findings.

How Presidents Viewed the Role of the Presidency

At one time, Presidents determined CAP strategy. During their terms as Presidents Elect, they were expected to produce strategic plans for the CAP that, pending Board approval, would determine the CAP’s course for their two-year terms as President. About a decade ago, CAP Presidents and Governors decided that resetting direction every two years was not in the best interests of the CAP and thus institutionalized strategic policy. Now, the Board of Governors, with advice from senior staff, is responsible for establishing a strategic plan, which is designed to span intervals far longer than two years. Correspondingly, Presidents currently view their role as that of Chairperson of the Board of Governors, responsible for orchestrating consensus on strategy and policy.

How Presidents Viewed the Board of Governors

Presidents unanimously commended fellow Board members for their motivation, selflessness, and knowledge. Some Presidents praised the wisdom of fellow Board members upon whom they could rely to offer challenging, sometimes iconoclastic resistance to majority notions, and in doing so prevent the Board from making ill-advised decisions.

However, several Presidents were puzzled by some Board members who at times appeared to be uncomfortable with, and thus unwilling to make difficult decisions. They feared these Governors approved decisions with which they might not have fully agreed.  Presidents also cited among some Governors, provincialism that may have resulted from their limited experiences beyond their own practice settings. These Presidents felt that such provincialism may have worked to inhibit growth and innovation, and perhaps represented potential conflicts of interests in which decisions might have been biased to promote the prosperity of certain types of practices at the expense of others.

How Presidents Viewed the Governance Structure

Presidents struggled to balance the relationship between an organization that on one hand, exists to serve the needs of its members and through its members, patients; and on the other, a business that fuels the resources necessary to meet those needs.  At one pole were Presidents who believed that the business focus of the CAP had migrated too far, resulting in swollen staff compensation packages and undermining the membership culture of the organization. As one President put it, “the [business focus] tail is wagging the dog.” They believed that the Board should comprise only pathologists, since pathologists bring to the governance table, experience with a wide range of professional practice environments that enable them to best understand and address the needs of their peers.

At the opposite pole were Presidents believed that in order to continue meeting the needs of its members, ensure the viability of the CAP, and perhaps ensure the existence of Pathology as a profession, CAP enterprise needed to continue growing.  These Presidents held that the complexities of governing a $200 million company demanded expertise beyond that which most pathologists can be expected to possess. As one President phrased it, “we don’t know what we don’t know.” Some Presidents suggested that several pathologist Board positions be replaced with non-pathologist, independent Governors capable of providing guidance in the sorts of commercial and non-commercial activities (e.g. business, marketing, government regulation) in which the CAP is engaged. Others would preserve the current Board composition and when confronting issues with which Governors were unfamiliar, engage knowledgeable experts to counsel them.

Several Presidents believed that at times, the governance structure complicated the interaction between Fellows and CAP staff. Because CAP staff are responsible for implementing initiatives designed to both meet member needs and advance CAP enterprise, they feared that actions advancing one agenda at times depleted efforts to serve the other. One President described this tension as competition between the Board and staff for control of decision making, often manifested as staff looking to make decisions “in a hurry.” Some Presidents saw the need for a “counterbalance” to staff opinions. One President remarked on the incongruity of the staffs’ mandate to serve members who have little formal input into the evaluations of those staff.

Insights for the membership

This survey of Presidents was not meant to be a history of who did what, information that Fellows may otherwise glean from reading “From the President’s Desk” in back copies of CAP Today and archival organizational transcripts maintained by CAP staff. Rather, these interviews were meant to provide our Presidents’ insights into the CAP’s governance system; information that might help Fellows sort out their future voting decisions.

The journey for Fellows who contemplate becoming CAP Presidents is long and arduous. Presidential hopefuls need to start early, gain years of experience serving in CAP leadership roles, and must be prepared to crisscross the country building peer networks.

All Presidents targeted goals they hoped to achieve during their terms, and in general believed they were successful in accomplishing those goals (Table 3). I did not attempt to evaluate the degree of their successes. The point is, they had goals. In evaluating Presidential contenders, Fellows may want to consider not just the backgrounds and experience of the candidates, not just the opinions of what the candidates say the “CAP” should do, but rather what they as people—Presidents–plan to accomplish during their terms.

The duties of the President are described in the CAP’s Constitution and Bylaws. Fellows may also want to ask that if Presidents’ primary roles are to chair the Board of Governors, is the CAP better served by elected or appointed Board chairpersons? Fellows might conceive of two roles: an elected President serving as spokesperson for the CAP and a Board Chairperson appointed by Fellow Governors.

That the inconsistency of how Presidents regard the relationships between CAP membership and business entities, and between member and staff decision makers has been festering for decades argues for demanding that our leadership come to consensus on written policies that define these relationships. Debating this balance will necessarily require discussions about whether we should add to our Board of Governors individuals with experience and expertise that our pathologist Governors may lack, and about how to prevent our mercantile endeavors from suffocating the membership.

 

Table 1: Living Presidents of the College of American Pathologists

President Years of Terms in Office
Herbert Derman, MD FCAP 1983-1985
William B Zeiler, MD FCAP 1987-1989
Paul Bachner, MD FCAP 1999-2001
Paul A Raslavicus, MD FCAP 2001-2003
Mary E Kass, MD FCAP 2003-2005
Thomas M Sodeman, MD FCAP 2005-2007
Jared N Schwartz, MD FCAP 2007-2009
Stephen N Bauer, MD FCAP 2009-2011
Stanley J. Robboy, MD FCAP 2011-2013
Gene N Herbek, MD FCAP 2013-2015
Richard Friedberg, MD PhD FCAP 2015-2017

 

 

 

Table 2: Ten Questions Presented to Presidents of the College of American Pathologists (CAP).

1. Why did you choose to run for the Presidency of the CAP?
2. What did you hope to accomplish during your term?
3.  Were you successful in accomplishing what you set out to accomplish?
4. If you believe that you were successful, what was the evidence of that success?
5.  If you believe that you were not successful, what do you believe prevented your success?
6. In either case, what was the biggest obstacle you encountered in attempting to achieve your goals?
7. What was the greatest asset the CAP afforded you in your attempt to achieve your goals?
8. What do you think are the major assets of the Board of Governors and/or the CAP Governance system?
9. What do you think are the major drawbacks of the Board of Governors and/or the CAP Governance system?
10. Is the CAP governance system, i.e. the Board of Governors optimized to advance the agenda of the CAP, and if not, how would you improve it?

 


 

Table 3: Outcomes of Goals Set by Presidents of the College of American Pathologists (CAP).

Tangible goals Presidents believed they achieved
·      Relocation and construction of physical plant.
·      Changing CAP governance and organization.
·      Overhauling the manner in which the President and Board determine CAP strategy.
·      Formation of new councils, committees, and programs
·      Convincing the American Medical Association to support, and federal regulatory agencies to adopt Pathology Current Procedural Terminology (CPT) codes.
·      Re-posturing of, and increasing attendance at the annual CAP meeting.
·      Reframing the CAP’s relationship with the American Society for Clinical Pathology
·      Selling and incorporating into the National Library of Medicine, the CAP’s SNOMED diagnostic coding system.
·      Strategic partnering with the Association of Pathology Chairs.
·      Restructuring, addition and subtraction of executive staff.
·      Expanding CAP business entities
Intangible goals Presidents believed they achieved
·      Building consensus among stakeholder pathologists.
·      Engaging peers to consider new practice strategies.
·      Establishing or changing organizational culture.
·      Improving patient care.
·      Improving the training of pathologists.

·      Influencing government laboratory health care regulations.
Goals Presidents believed they did not achieve during their terms as President

·      Modification of CAP finance and budget planning.
·      Redesign of CAP governance structure.
·      Securing American Medical Association’s support for CAP initiatives.
·      Integrating of state Pathology societies into the CAP advocacy system.
·      Extending scope of CAP membership.

 

COMMENTS ON BLOG

Goals? Yes – Strategy for implementation? Definitely!

November 22, 2017 06:50 PM by Karim Sirgi, MD, MBA

It is important to recognize that even when aspiring presidents come to the position with personal accomplishment goals for the organization, the ultimate goals and strategy of the College are established by the Board of Governors (BOG), presided of course by a fellow member. It is therefore  as important to select the “right person” to serve on the BOG as it is to elect the “right” president.

The right dynamic between board members within the BOG, between board members and senior CAP staff, and an open, continuous and respectful communication with the membership at large are truly the real ingredients of success (or lack thereof) in an organization such as ours. Even armed with the best intentions, the president cannot succeed alone without the appropriate mix of such ingredients.

 

Selecting the “right” people

November 24, 2017 08:31 AM by David Novis

Thank you for your insightful comments, Karim. I believe our past presidents would agree with you that it is critical that CAP members select the “right” people to serve on the Board. My takeaway from their comments is that in choosing Board members, we should first consider some basic elements of governance that all  boards consider before populating their chairs: Are governing boards better served by electing or by appointing some or all of their members? Should we consider adding to our Board, independent perhaps non-pathologist governors who possess experience and expertise in areas that the CAP requires but that our peer pathologists may lack? Difficult conversations to be sure, but conversations worth having nonetheless.

 

CAP board

November 24, 2017 02:58 PM by Alfred Campbell

Very well done David. I commend you for taking the initiative on this. The comments are not unlike what ex-CEO/Presidents of other organizations say after they have moved on. You have given me a lot to ponder. I thank you for that!!

 

More on choosing leaders…

November 24, 2017 07:36 PM by Paul Valenstein

Populating an organization’s board and its officers with the “right” people presents challenges for the CAP and for many other non-profit membership organization.

A requirement that Board members also be members of the organization itself (“Fellows” in the College vernacular) has advantages and disadvantages.  On the “plus” side, this requirement ensures that the organization doesn’t drift too far from where the membership believes it ought to go — everyone on the Board is a CAP Fellow.  But there are also minuses – restricting board membership to CAP Fellows reduces the diversity of perspectives on the Board. Sometimes, seasoned individuals from outside the organization and specialty can see the landscape and options more clearly than those of us immersed in practice.

A requirement that all board members and officers be elected, rather than appointed, also has advantages and disadvantages. Election of governors and officers ensures that board members generally reflect the values of the membership. But it can be difficult for Fellows to know in advance how well a candidate will function in a board setting or as an officer. Furthermore, individuals with minority perspectives or alternative career trajectories often find it difficult to be elected by the general membership. A “slotted” position for a resident helps ensure one particular minority perspective is heard, but there are other minority views that might be better developed and represented.

Finally, the CAP requirement that governors also shoulder significant council responsibilities limits board membership to individuals who can devote a great deal of time to their governance and leadership duties. This service requirement ensures candidates for the board are committed to the organization (which is good), but makes the role very difficult for mid-career pathologists and individuals outside of pathology who have comparatively less time to donate.

In my experience as a CAP board member and officer, I found the existing system for selecting board members and officers worked reasonably well. It is difficult to be sure any alternative approach would produce better results, although it might.

I can think of two variants that might be worth debating: Readers can consider the pros and cons of (1) the board appointing (or the fellowship electing) 1-2 governors who are not pathologists, and (2) creating 1-2 board positions that have fewer council and non-governance responsibilities.

Anyone want to argue for or against either of these variants?

 

Choosing Boards of Governors

November 26, 2017 09:06 AM by David Novis

Thanks so much for your comments, Paul as always thoughtful and perceptive.

You state with such conviction that restricting board memberships to dues paying members “ensures” that organizations will steer themselves in directions in which boards “ought” to go. That implies that boards comprising only organizational members never, or at least hardly ever chart courses that veer from their missions and visions (my definition of “ought.”).  Certainly, your contention makes sense but making sense does not make it so. I wonder if there exists documentation that decisions made by boards comprising independent directors–directors bound by fiduciary responsibilities to advance the agendas of the organizations they represent—drift from organizational missions and visions more commonly than boards comprising only member directors.

Some of our colleagues might fear that they will lose control of their organization if they install several independent directors on our Board of Governors. It is easy to confuse “governance” and “control.” As you well know, governing boards exist to guide organizations in getting where they “ought” to go. Control is always in the hands of its members (or stockholders). Members have the power to dissolve and reorganize their boards when they think their boards are no longer advancing their interests.

Most presidents would agree with you that appointing rather than electing at least some fellow Governors might improve the level of competence at the Board table. They would also agree that boards with appointed “slots” are better able to fill a variety of gaps, such as those that may exist for gender, ethnicity, training level, etc. But those were not the main reasons they cited.  Presidents saw that their Boards lacked critical expertise that pathologist Governors could not, nor could be expected to possess, and which they could not rely on elections to provide.

Your comment that election of governors and officers “ensures” that board members generally reflect the values of the membership assumes a cause and effect relationship. Perhaps, but I am unaware of documentation that supports such a relationship. More importantly, that notion assumes that our 18,000 members embrace one collective value. My experience as House Speaker suggests quite the opposite.

I agree with you that having Governors chair councils is an onerous responsibility. But I believe this has less to do with validating commitment than it does with educating governors in all aspects of this large complicated organization so that when moments arise, they can make intelligent decisions.  As you note, the enormous amount of time this requires shuts out so many younger talented women and men who are at stages in their lives where they must exploit what little they have of it to raise families and build practices. Mitigating this inequity might require compensating Governors, a weighty debate in itself.

Finally, having served as an ex officio member of the Board of Governors, I am unable to agree or disagree with your reflection that the “system for selecting board members and officers worked “reasonably well” without knowing how you define “reasonably well” and to what outcomes or control groups you are comparing this performance.

I hope others weigh in on this provocative debate. Again, thanks for keeping it alive.

 

Healthcare Thinking Part 1

Our executive and legislative tribal leaders vow that their fight to replace the Affordable Care Act is not over. The rhetoric that accompanied the most recent skirmish seemed to me to have more to do with political domination than it did with solving our nation’s healthcare delivery problems. In this next battle, the combatants will again attempt to trap and confuse us in a crossfire of oversimplified solutions to complex issues that defy simplification. I am posting this month and next, a two-part article written in 2015 by economists Gregory Shea and Bruce Gresh. In their timeless, lucid perspective, Drs. Shea and Gresh guide us through the minefield that attempts to provide unrealistically simplistic solutions to convoluted healthcare issues.

View Full Article

(With permission from Dr. Gresh)

Alisa Ottman, MS — Quality Management and Regulatory Compliance

Alisa Ottman brings to Novis Consulting over 20 years of Quality Management expertise. Ms. Ottman is a “best practices” expert, a certified CAP laboratory inspector and a lead ISO program certification manager. She has developed quality systems compliant to CLIA, CAP, New York State, FDA and ISO (9002). Alisa has additionally provided regulatory support by obtaining CMS licenses for clients. Alisa routinely works with clients with multi-certification sites and laboratory developed tests.

Ms. Ottman graduated with a Bachelor’s of Science in Biology from UC Davis and holds a Master’s degree with honors in Management, Life Sciences from George Mason University.

Lab Work

 Dr. David Novis has sound advice for hospital administrators not quite up to speed on the inner workings of their lab.

For more than a decade, the CEO of Community General Hospital (CMG), a 120-bed, non-profit facility serving a population of 50,000, had contracted with a three-physician pathology group to provide pathology services and oversee the operation of its full-service clinical laboratory.

From the CEO’s perspective, the arrangement worked well. Lab tests all seemed to get done, doctors didn’t complain much, and the laboratory maintained its accreditation by the prestigious College of American Pathologists (CAP). But things changed abruptly.

An unannounced CAP inspection turned up enough deficiencies to place the lab’s accreditation status on probation. This was a disaster. The confidence of patients and physicians in the quality of the hospital’s services was undermined, and plans to issue a bond financing the new ambulatory wing had to be put on hold. How could things deteriorate so quickly?

Perhaps previous CAP inspectors had been lax. Perhaps previous successes in achieving CAP accreditation had lulled laboratory personnel into a false sense of security. Maybe key personnel were no longer assigned to oversee critical laboratory functions. Regardless of who dropped the ball, the ultimate responsibility for making sure all critical functions required for CAP accreditation were in place belonged to the laboratory’s medical director. The hospital administrator assumed that the pathologist had been running the lab—but what did that actually mean?

 Broad Scope

Most hospital laboratory medical directors are medical doctors, and most of those  doctors are pathologists. The scope of their work is broad, including (but not limited to) examining tissue samples and blood smears under the microscope, performing certain types of biopsies, obtaining bone marrow samples, and interpreting laboratory data.

Pathologists are commonly reimbursed for these services by billing patients or their proxies directly. Their work is scrutinized daily by the physicians who must use this information to care for their patients.

Hospital administrators, however, are primarily concerned with pathologists’ administrative responsibilities. Pathologists are commonly reimbursed for these services by hospitals that contract with them for administrative services. As at CMG, as long as things seem to be going well, administrators are unlikely to concern themselves with the details of performance or even question the value they are receiving.

Responsibilities

Here are five key responsibilities of the laboratory medical director.

  1.  Ensure that laboratory services meet the needs of, and are used properly by, the medical community. To accomplish this, laboratory directors must oversee laboratory quality improvement programs and provide the interface between the laboratory and those accrediting organizations that serve as watchdogs of laboratory quality. Directors often supervise mock inspections of their laboratories using checklists and criteria of the organizations and agencies from which they are seeking accreditation. As hospital-based physicians, laboratory directors must also provide leadership in hospital-wide quality improvement programs.
  2. Ensure the reliability of laboratory data. Physicians place their unbridled trust in laboratory test results. Laboratory medical directors must guarantee doctors that all data emanating from the laboratory is accurate beyond question. Anything less undermines the confidence of physicians and patients in the integrity of laboratory and, by association, the hospital.
  3. Consult with and communicate laboratory data to healthcare providers. Pathologists may advise clinicians on which tests best diagnose suspected diseases, which test results are distorted by drugs their patients may be taking, and how test results may be interpreted in their patients’ unique environments. Sometimes this involves hands-on activities such as viewing either peripheral blood smears under the microscope or bacterial culture patterns on agar plates. In all cases, laboratory medical directors must make sure that test results are reported quickly enough to allow doctors to initiate therapy in a timely manner.
  4. Interact with the medical and patient communities. As medical directors of major hospital departments, pathologists are consultants to the entire community of healthcare providers. As such, they must contribute eagerly to their hospitals’ continuing medical education programs by conducting lectures, grand rounds, and specialty conferences. Hospital administrators view their medical directors as upper-level executives and may require them to provide leadership on key governance committees.
  5. Oversee all aspects of laboratory management. Keeping an eye on the shop is the nuts and bolts of what laboratory medical directors do. They prepare operational and capital budgets and strategic plans. They attend and/or chair laboratory and hospital management team meetings. They conduct research and development, select and monitor subspecialty reference laboratories, and interact with equipment vendors. Director’s comments appear on reports of applicant interviews, employee job performance, and equipment evaluations.

 Documentation

Laboratory medical directors gather, review, process, and interpret various sources of data. Their involvement in these activities is recorded in their signatures and commentaries that appear in documents that contain this data. Some of this data is objective; some is subjective. The list of documents containing this information includes:

* Metrics of laboratory services such as rates of laboratory test turnaround times, lost specimens, laboratory testing errors, unsuccessful phlebotomies, and computer downtime. Directors can choose to develop these metrics internally within their institutions or purchase benchmarking and analysis packages containing these metrics.

* Operational checklists, testing protocols, results of daily quality control, ranges and tolerance limits of test results, reports of laboratory errors, and customer complaints.

* Diaries and logs of consultations with physicians, hospital staff personnel, and patients.

* Memoranda and reports issued to the hospital medical and nursing staffs.

* Patient, physician, and hospital staff satisfaction surveys, especially point-of-service questionnaires such as those used in electronic and automobile repair facilities. These surveys are crafted to document the value with which customers view laboratory services.

* Minutes of meetings held by laboratory management, medical staff departments, and hospital committees.

 

Checklist for administrators

Talk to doctors. Some hospital administrators determine whether or not laboratory services are meeting the needs of healthcare providers by waiting for angry physicians to complain. More savvy administrators periodically approach key physicians individually for their opinions before problems surface.

Read the minutes. Problems with laboratory services may surface first in the minutes of key hospital committees such as medical executive and quality.

Review the logs. Laboratory consultation, operational, error identification, mock inspection, and complaint logs will give administrators a handle on how their laboratory directors deal with problems and whether or not the corrective actions they pursue are appropriate and productive.

Keep an eye on the charts. Regularly review the results of laboratory quality indicators and satisfaction surveys.

 Be consistent. The documentation required to assess the effectiveness with which laboratory medical directors function in their broad roles as hospital executives should mirror those used to assess the effectiveness of executives elsewhere in the healthcare system.

Maximize success

Not all pathologist directors possess the same managerial abilities. Whether or not a candidate possesses all the necessary skills required to run laboratories is better assessed not by their pathologist trainers and colleagues, but by the hospital administrators ultimately responsible for the hospital and everything in it. Here are six ways hospital administrators can maximize the success of their pathologist laboratory medical directors.

Control the process from the outset—hiring. Administrative and management training has never been the strong suit of pathology training programs, and there are no guarantees that newly trained pathologists have the skills to oversee the direction of laboratories. Hospital administrators who have much to risk in these appointments are likely to be better able to evaluate pathologist applicants than are other pathology service providers.

 Make sure the laboratory directors understand their roles. Contracts are not enough. Certainly contracts with pathologists are needed to spell out their duties as  described above. But for laboratory medical directors and hospital administrators to interpret the language in precisely the same dialect, they must sit down and discuss job expectations in detail. Once everyone is on the same page, administrators must grant pathologists the authority they need to carry out their  tasks. Keep in mind that you may want your pathologist directors to perform other functions not spelled out by regulatory and accreditation agencies.

Secure your investment. Assess skill levels. Determine what additional training laboratory medical directors need to bring them up to the same levels of competency required of your other health executives. Hospitals administrators may decide that it is more efficient to allow their medical director to delegate certain functions to other laboratory personnel, but keep in mind that delegation is not the same thing as abrogation. As stated in the standards of the CAP, “The director remains responsible for the overall operation and administration of the laboratory to assure that quality patient services are provided.”

 Instill the vision. Agree on outcome measurements of success and failure. Standards of excellence must be uniform throughout the hospital. Pathologist medical directors must understand that that they are being evaluated by the same criteria and processes used to judge top administrators elsewhere in the hospital. The laboratory medical director and the hospital administrator must agree on the rewards and penalties for exceeding, meeting, and failing to achieve the desired performance.

 Ensure success. Put the pathologist on your management team. If pathologists are to function as managers, they must be treated as such. They must attend selected meetings of the management team, have the opportunity to participate in educational conferences available to other hospital managers, and be assimilated into other activities and projects that develop their accountability as medical executives.

 

Maximize credibility. Make quality the top priority. The pathologist must champion the culture of quality as established by the hospital trustees. The laboratory medical director must ensure that the letter and spirit of CAP quality is maintained in the laboratory. These mandates will likely require the pathologist to oversee the development of quality assurance programs in the laboratory and to integrate these programs into the quality assurance programs of the medical and hospital staffs.

 

Don’t get caught in a pinch. Develop contingencies. In the end, some pathologists may not have the horsepower to be managers or may require more resources than you want to commit to turn them into managers. Yet it may be unwise to terminate the pathologist’s employment, especially if the pathologist commands considerable professional respect among the medical community. Consider amending the medical director’s contract and hiring other individuals such as a non-pathologist PhD or MD or a pathologist from a neighboring practice to run the laboratory.

 

Dr. David Novis has practiced laboratory medicine and pathology for 25 years and is a recognized expert in clinical quality, medical outcome assessment, patient safety, medical service delivery and best practices methodologies. He is a senior consultant for Chi Solutions, Inc. He can be reached at www.davidnovis.com

Requisites to Strategic Planning

Until a few years ago, the business environment for the practice of pathology was robust: stable third-party reimbursement, high revenues, content customers, and negligible competition. However, that environment is changing and the future does not look so favorable. Reduced federal and third-party reimbursements will diminish practice revenues. 1 Fee-for-service is on track to morph into value-based remuneration2, a paradigm shift that will likely have pathologists bickering with their colleagues for a fair share of the reimbursement check. The proliferation of pathology specialty training programs3 will likely escalate customers’ demand for specialized pathology expertise, diverting yet more work from generalist pathologists who never dreamed that work to be at risk. Mergers, consolidations, and acquisitions may eliminate
pathology positions altogether. Pathology groups may be forced, perhaps for the first time, to engage in high-level business strategic planning, the stakes of which are the very preservation of their livelihoods.

In many practices, several partners hold equal equity and hence equal voices in decision making. Finalizing strategic business decisions requires group consensus. For
some groups, reaching consensus decisions may be difficult. As requisite to strategic planning, partners in those practices might be well served by answering several questions.

WHAT IS THE ‘‘CULTURE’’ OF OUR GROUP?

By ‘‘culture,’’ we mean the way members of an organization choose to behave collectively: their beliefs and values. It is the glue that holds organizations together. Group culture is built on mutual trust, respect, and transparency.4 It stands to reason that to achieve a homogeneous, harmonious group culture, group members must know and understand each other’s needs and personal goals. It is not realistic to expect everyone to share the same needs and goals. The aspirations, lifestyles, and professional requirements of pathologists are likely to differ at various stages of their careers. Single parents may need to be home at 3 PM to meet school buses; pathologists in mid practice may need to work overtime to meet tuition bills; and older
members late in their practice careers may want to work half time, no weekends.

As diverse as these needs may be, groups often require that all members conform to single practice and workload distribution models, which in fact may work ideally for no one. Members whose life and practice goals invite long workdays conflict with those whose view of the world does not. They may suspect that group workloads, and hence group incomes, are distributed inequitably. ‘‘Cultural differences’’ becomes a euphemism for ‘‘he doesn’t work as hard as I do.’’ The results of this cultural autocracy are likely to be vilification of colleagues, infighting among grouppartners, and collapse of consensual decision making.5

Unless practice groups establish common cultural platforms and visions that incorporate the divergent needs of all constituents, it may be impossible to reach business decisions.
Even if groups do have common visions of their future, they may not have appreciated the necessity of factoring into their hiring decisions, the affinity of new recruits—new
recruits who may someday be full voting partners—in sharing them. Practice groups might want to consider whether their long-term interests are well served by including, on their interview checklists, the preferences and goals of prospective group members.6

HOW WELL DO WE WORK AS A TEAM?

Some practice members may find that working independently in cloistered silos improves their productivity. However, operating alone in silos rather than collectively in teams erodes mutual trust and with it, the ability to compromise, an essential requirement of consensual decision
making. One measure of a group’s ability to make collective decisions is ‘‘group IQ,’’ defined as the sum total of the talents of each group member. Teamwork raises group IQ; working in silos lowers it.7

Group IQ depends not on intellectual IQ, but rather on ‘‘emotional IQ,’’ those human qualities such as empathy, social skills, self-awareness, and self-efficacy. By connecting the emotional IQs of individual members, groups are able to aggregate talents and raise their group IQ, the end results of which are improved organizational performance, productivity, and decision-making ability. Conversely, organizations with low group IQ become paralyzed, dysfunctional,
and often dissociate under pressure. Members tend to suffer from burnout, exhaustion, and cynicism. Eventually, productivity—the original advantageous characteristic of solo
performance—is undermined. Decision making suffers.

Pathology practices may find it necessary to assess their group IQ and if low, explore ways to increase it.

HOW DO WE PROCESS INFORMATION?

To arrive at decisions, some individuals require possessing in hand clear tangible data, while others may prefer abstract, conceptual, and big-picture information. Some individuals base decisions on objective analytic data that focus on outcomes. Others make decisions on visceral and value oriented perceptions that focus on the impact those decisions have on other people. Individuals who grasp big pictures intuitively may view details as nuisances, the removal of which they are comfortable with delegating to subordinates. Detail-oriented people who become paralyzed by what they view as the enormous complexity of operational technicalities may be unable to navigate to, or even visualize, end results.8

Practice governing boards may need to establish protocols for decision making in which big-picture strategy drives tactics (not vice versa) and in which strategic outcomes are
defined by outcome metrics, timetables, and contingencies when those metrics and timetables fail to meet expectations.

WHAT IS OUR LEVEL OF BUSINESS ACUMEN?

It is probably fair to say that most pathology practices seek to recruit pathologists who have demonstrated, in their previous residency or practice positions, high levels of professional expertise. After a period of time, pathology practices may offer full-equity business partnerships to those recruits who continue to demonstrate acceptable professional acumen.9

There may be no guarantees that either the ambient or the recruited physician partners have
the experience, aptitude, and skills in making, executing, and evaluating business decisions. Partners may be happy to abrogate business decisions to peers who seem to be the
least incompetent business decision makers, but by no means have demonstrated favorable track records in commerce. Lack of proficiency raises the probabilities of
decisional inertia and worse, fiscal misadventure.

Furthermore, by stealing time from the relatively high revenue–generating activities of practicing pathology, delegating business activities to physicians is financially inefficient. Finding themselves in leadership vacuums, some practices hire chief executives. If executives meet groups’ expectations, partners may offer them equity positions, the magnitude of which they may tie to continued success andcorporate growth. As logical as this solution may appear to
some group members, others may wrestle with perceived loss of control. They may find it difficult to separate their roles involving governance and strategic planning from
executives’ roles involving operations and tactical execution.10

In order for corporate practice arrangements to work, practice partners may need to draft governance documents that define the ground rules and borders of governance and
operations.

CONCLUSIONS

To be successful, strategic planning requires more than a weekend retreat. It requires considerable requisite preparation. Its tipping point is the establishment of a common
culture. Culture drives the strategy, not the other way around. Practice group partners must commit to resolve polarizing differences and work together as a team. They must set ground rules for processing information, reaching decisions, and tracking the successes or failures of those decisions. Finally, business leadership must be delegated in a fiscally efficient manner to those with the expertise and \experience to provide it.

References
1. Centers for Medicare and Medicaid Services. Details for title: CMS-1600-
FC. CMS.gov Web site. November 27, 2013. http://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-
Notices-Items/CMS-1600-FC.html. Accessed March 26, 2014.
2. Centers for Medicare and Medicaid Services. Accountable Care Organizations
(ACO). CMS.gov Web site. www.cms.gov/Medicare/Medicare-
Fee-for-Service-Payment/ACO/. Accessed March 26, 2014.
3. Fellowship Directory. Pathology Resident Wiki. Wikia. http://pathinfo.
wikia.com/wiki/Fellowship_Directory. Accessed April 3, 2012.
4. Hurley RF. Group culture and its effect on innovative productivity. J Eng
Technol Manage. 1995;12:57–75.
5. Glaser J. Moving from distrust to trust. Conversational Intelligence. New
York, NY: Bibliomotion, Inc; 2014:54–55, 80.
6. Liker J. Principle 10: develop exceptional people and teams who follow
your company’s philosophy. The Toyota Way. New York, NY: McGraw-Hill; 2004:
187–188.
7. Goldman D. People skills. Working With Emotional Intelligence. New York,
NY: Random House, Inc; 1998:198–231.
8. Quenk N. How to interpret the MBTI instrument. Essentials of Meyers-
Briggs Type Indicator Assessments. Hoboken, NJ: John Wiley & Sons Inc; 2009:
53–90.
9. Valancey J. Tying the partnership knot: making it a win for both practice
and associate. Family Practice Management. American Academy of Family
Practice. March-April 2009. http://www.aafp.org/fpm/2009/0300/p23.html. Accessed
March 26, 2014.
10. Business Roundtable. Principles of corporate governance 2012. http://
businessroundtable.org/sites/default/files/BRT_Principles_of_Corporate_
Governance_-2012_Formatted_Final.pdf. Accessed March 26, 2014.
306 Arch Pathol Lab Med—Vol 139, March 2015 Editorial—Novis et al

Keith J. Kaplan, MD FCAP — Pathology Informatics, Digital Imaging

Keith J. Kaplan, MD, is a nationally recognized expert in hyperspectral imaging, image analysis and the use of Web 2.0 tools in pathology. He has authored over 60 peer-reviewed scientific papers and lectures internationally  on topics of pathology informatics.  Dr. Kaplan founded and directed the Army Telepathology Program, a telepathology consultation program that connects 25 hospitals throughout the world. Dr. Kaplan is the publisher of the Digital Pathology Blog at tissuepathology.com.

Dr. Kaplan is currently the Chief Medical Officer at Corista, Concord MA, a leader in digital imaging software.  Previously Dr. Kaplan practiced pathology and was a laboratory medical director for  Carolinas Pathology Group, Charlotte NC,  and was an Associate Professor of Pathology at Mayo Medical School,  Rochester, MN.

Dr. Kaplan received his BS degree at Michigan State University and MD degree at Northwestern University’s Feinberg School of Medicine, He completed his residency training  at Walter Reed Army Medical Center, Washington, DC. and is American Board of Pathology certified in anatomic and clinical pathology.

 

College of American Pathologists CAP Connect blog

On Time Deliveries: The Wrong Metric?
By: David Novis on Jun 10, 2015

Recently, Volmar and colleagues’ published a meticulous and well-crafted Q-Probes Study of large specimen turnaround time (TAT). In it, they offered their observation that without knowledge of corresponding clinical outcomes, it may be impossible to assess the value of TAT measurements.[i] That comment made me wonder whether we are spinning our wheels by shaping our services on data that may be meaningless to the very people those services are intended to benefit.

TAT is a quality control measure of process. TAT measurements gauge efficiency, which as the authors note, provide value to those pathologists who use the data to calculate workload requirements. Certainly, it is in pathologists’ interests to reduce TAT and its companion, throughput: slide boxes left untouched today will only accrue work hours tomorrow.

But why should our customers want to concern themselves with our operational efficiency? I suspect they care only about outcomes—not how long it takes us to turn out our reports, but only whether or not they have those reports in hand when they need to make treatment decisions.

We may be beating ourselves up to collect measurements that our customers find meaningless. In fact, previous Q-Probes Studies have shown that most of us turn out PAP smear reports in a week[ii] for physicians who may not look at those reports for months.[iii]

Worse, TAT measurements may actually distance us from our customers. When clinicians react negatively to the few pathology reports that are not on their desks when patients return for their follow up visits, the last thing they want to hear in defense is how our other report TATs exceed national benchmarks.

Perhaps it is time we adopted the standard metric by which all other industries gauge timeliness of service, one for which their customers perceive value, namely measurement of “on time deliveries (OTD).”[iv]

Procedurally, pathologists may find measuring OTD less burdensome. For instance, rather than tracking the lives of all reports, they might concern themselves only with detecting outliers—the percentage of reports that do not hit their targets on time. Systems that track outliers might need only rely on customers to inform us when reports miss deadlines. If done in real time, pathology staff persons can perform root cause analysis of those outliers and correct problems immediately.

Any mechanism that pathologists design to measure OTD requires that they partner with individual customers to determine delivery specifications that are achievable and relevant. And herein lies the real value. From that perspective, transitioning from TAT to OTD may demonstrate to our customers our sensitivity to their needs, develop the sorts of relationships that reinforce the value that pathologists bring to health care, and undermine misguided notions that pathology services can be commoditized.

[i] Volmar et al. Turnaround Time for Large or Complex Specimens in Surgical Pathology. A College of American Pathologists Q-Probes Study of 56 Institutions. Arch Pathol Lab Med. 2015;139:171–177
[ii] Jones BA, Valenstein PN, Steindel SJ. Gynecologic Cytology Turnaround Time. A College of American Pathologists Q-Probes Study of 371 Laboratories. Arch Pathol Lab Med. 1999;123:682–686.
[iii] Jones, BA, Novis DA. Follow-up of Abnormal Gynecologic Cytology A College of American Pathologists Q-Probes Study of 16 132 Cases From 306 Laboratories Arch Pathol Lab Med. 2000;124:665–671.
[iv] Kay, Simon. On-Time Delivery: The Measurement that Matters GCI Business Management http://www.gcimagazine.com/business/manufacturing/supplychain/133094458.html?page=1 accessed March 1, 2015.

Is It Time for a Change in CAP Governance?
Posted by David Novis MD FCAP
June 5, 2014

The members of the CAP House of Delegates (HOD) had no difficulty abrogating their charge as the CAP’s “legislative body” once they realized it to be an illusion that did more to weaken than it did to strengthen their ability to influence College policy. I suggest that the membership of the College now reevaluate the charge and structure of College governance.
To date, the College has taken great care of us. But that may be despite rather than because of our governance system.

Times used to be good. Fees for services were generous, urologists sent all their biopsy samples to us, and Medicare paid their outpatient lab bills. Times are no longer what they once were. I believe that the shifting plates of health care may expose and fracture the faulty seams of a system conceived in better days.

At the center of our governance is the Board of Governors (BOG). The BOG is charged with setting College policy and ensuring that its implementation meets the needs of our 18,000 members. What makes governing the College so complicated is that the CAP is really two organizations: a professional society and a $170 million business. The business is our air supply. The revenues it generates fund the services upon which the professional membership needs to survive, not the least service of which is political advocacy.

The Board comprises twelve Governors, three officers and four ex-officio members. They are all pathologists. Having served on the Board for four years, I can tell you that our Governors are sincere, hard-working and committed to the constituents who elected them. But they are all pathologists. The perspectives they bring to the boardroom reflect their own, unique, personal experiences accumulated in their training and practice of Pathology. Sitting at the table are no independent directors chosen solely for their expertise in running a $170 million business. It is not reasonable to expect the board’s pathologists to possess those skills. In a sense, we have a board of directors consisting entirely of plant managers.

This means that we have no impartial insight to guide our decisions. When our upper level staff presents their plans to enter foreign markets, there is in the room no CEO of a multinational corporation to challenge them. There is no investment banker to question how our money managers invest our sizable portfolio. There is no nationally recognized marketing guru to offer alternative approaches as to how we might market our proficiency testing products.

That is not to say that our executive staff lacks ability. In my estimation, they are probably the best in the industry. But with the exception of the CEO and CFO, their counsel comes unhindered by the requirements of fiduciary responsibility. It’s one thing to provide expert opinion. It’s quite another to provide it with the conditions of fiduciary responsibility.

I think it is time for us to rethink our governance system. We need to either populate our governing board with independent directors or create a second board comprising industry leaders to oversee our commercial interests.

A Shortage of Pathologists. The right solution?
Posted by David Novis MD FCAP
May 29, 2014

I don’t know if the CAP’s predictions about an impending shortage of pathologists are accurate or not, however I do agree that having contingency plans for worst-case scenarios makes sense. Unfortunately, as best I can tell, our leaders charged with formulating these plans have alighted upon one solution and one solution only: train more pathologists.

I can see where convincing fiscal gatekeepers to fund population Earth with more pathologists serves the interests of the training programs and specialty pathology societies whose emissaries comprised the Pathology Workforce Summit. Whether or not that argument holds any weight with your average working pathologist might be another story.

In any other industry, contingency plans would include a whole lot more than one solution, and adding more labor would likely be the very last one on the list. Rather than throw more people at the problem, production engineers would brainstorm system changes that get more work done with less people. And incur fewer errors to boot. For instance, they might consider how pathologists can make better use of their physician extenders, develop laborsaving technology, and eliminate wasted steps in producing diagnoses.

No, I don’t have the answers. That’s the point.  The CAP needs workgroups to brainstorm solutions to a potential shortage of pathology coverage (which is not necessarily the same as a shortage of pathologists) other than a manpower workaround.  If efforts to open more training programs fail, which I believe is more likely than not, and we become spread too thin to provide pathology services that our customers need, I fear that not only will we be inviting other professionals to step in and do what we are unable to do, we will have lost an opportunity to learn the skills of efficiency that our healthcare consumers—and healthcare reimbursement–demand.

Workforce Strategy: Aiming for the Wrong Target?
Posted by David Novis MD FCAP
May 20, 2014

In their zeal to protect our livelihoods by staving what they believe will be an alarming shortage of pathologists, our well-intentioned leaders may have set their sights on the wrong target.
A recent CAP study concluded that over the next two decades, the pathology workforce would find itself 14,000 FTEs short, a gap that would require swelling residency training programs about 8% to plug. [Robboy et al, Arch Pathol Lab Med. 2013 Dec;137(12):1723-32.]

The study based their calculations on all sorts of assumptions about emerging technologies, practice behaviors, utilization, and the use of ancillary personnel. There is no way of knowing the accuracy, let alone the shelf life of these assumptions and hence the validity of the predictions. However, if they are anywhere near accurate, the consequences of doing nothing will be unpleasant for all of us.

To avert what they see as a potential disaster, this past December representatives from the CAP and 24 other professional pathology and medicine organizations held a Pathology Workforce Summit. They identified threats to pathology workforce supply and demand and considered whether training programs will be able to meet the needs of employers and pathologists newly in practice. The CAP Policy Roundtable has established a Workgroup on Workforce and Graduate Medical Education to deal with the issues identified at the Summit.

Among other challenges, the coalition plans to compute how many residents we will need, in what specialties they need to be trained, and how training programs will fill this capacity. But they are launching into this without first defining an end point. How do we know when we have enough doctors? When it takes graduating residents 18 rather than four months to find placement, if indeed they find places at all? When the labor surplus has potential pathology residents considering other specialties? When the glut of pathologists precipitates a 40% drop in fixed-rate reimbursement?

We need to know precisely what target we are aiming for, and it’s probably a good idea to do that before we launch a missile that we may not be able to recall.

Now is the Time to Re-arm Ourselves: Requisites to Strategic Planning
Posted by David Novis MD FCAP
December 19, 2013

The smoke surrounding the impact on pathology of CMS’s long-awaited Final Physician Fee Schedule finally cleared on the eve of Thanksgiving Day, revealing battles both won and lost. As unwinnable as some of those battles were, it may still be difficult for some of us to accept losing them. That’s understandable.

Our Advocacy division has racked up an impressive list of victories—securing CLIA provisions legislating our employment as laboratory medical directors, propelling legislation that will likely close the Stark loophole, derailing a competitive bidding initiative for clinical lab tests, among others. Indeed, the College has established itself as the only credible organization capable of representing, and achieving political victories for, pathologists.

Yet, I fear that Advocacy’s extraordinary success over the years may have some of us relying too heavily on political warfare to preserve our livelihoods. The terrain of the past may have tilted the outcomes in our favor. Now, the landscape is changing. Consolidations threaten to deplete our ranks. New technologies will likely undermine our current tactics. Disappearing fee–for-service reimbursement will change the game altogether. We cannot assume that advocacy alone will preserve the steady flow of 305’s and laboratory medical directorships.

We still need every member in there together to fight our Advocacy battles. That will never change. However, we must each arm ourselves for the new millennium. We must invest in new strategies and services. Anticipating these trends, the College is providing us the necessary ordnance. To get started, look no farther than the CAP website. Promising Practice Pathways will provide you the vision. The Learning Portal will provide you the education in that health care will soon be requiring of pathologists: genomics, molecular, informatics.

From there it’s up to each of you to deploy your medical expertise in new ways in this uncertain environment.

Suggestions for Sharpening Your Competitive Razor
Posted by David Novis MD FCAP
October 11 and 12, 2013

The afternoon session of tomorrow’s fall 2013 meeting of the CAP House of Delegates will be devoted to a discussion of a large white elephant sitting in the corner: competition among pathologists.

When I went into practice in 1980 nobody in my group considered that pathologists residing elsewhere would nibble away at our pie. That all changed a few years later thanks to managed care. To grow our practice–let alone stay alive –we knew that customer service had to replace notions of entitlement. Today, consolidation of health care institutions, employment of our clinician customers, dwindling reimbursement and the inevitable demise of fee-for-service conspire to advance that understanding to a level of necessity.

At tomorrow’s HOD session, several of our peers will describe how their pathology practices keep the wolf from the door. Today and tomorrow, I will share what worked for our practice.

• Customizing reporting templates. When we began using template reports in 1982, our customers stopped calling to ask about information we had forgotten to include in those reports. They especially liked being able to locate the information they were looking for in the same place in every report. The templates worked so well, we soon had our clinicians participate in crafting them. Our competitors could not or would not do that. Our customers felt as if they now owned a piece of the real estate in those reports and they were not about to give that up to our competitors.

• Customizing services. It began with one OBGYN group fretting over losing follow-up patients with dysplastic smears. So once monthly, we sent them print-outs of patients with positive Pap smears on whom we had no follow-up biopsies. The numbers of biopsies soared. Our competitors balked at doing this. We offered it to everyone and we picked up two new OBGYN practices.

• Featuring digital photos on surgical and autopsy reports. Not a big deal now, but it was in 1983, when we began embedding photomicrographs in surgical reports. Yes, placing arrows on lymphocytes traversing colonic epithelium and drawing measurement brackets on tumors was time consuming. But it also resulted in in phone calls expressing gratitude. In fact, doing something as simple as placing pictures on autopsy reports helped us win customers and capture the cash-rich, otherwise shunned autopsy business for the entire five-hospital Seacoast region of New Hampshire.

More to come tomorrow on how we sharpened our competitive edge by double reading of all surgical specimens, reported our batting averages, and sent postcards from the edge (these strategies and more). In the meantime, what’s working to set your practice apart from your competitors?

• Postcards from the edge. We never wanted to learn that customers were unhappy with us by noticing that we were no longer receiving their specimens. In fact, we didn’t even want discontent to incubate to the level of a vocal complaint. So, in the days before Internet reporting, we would affix stamped, addressed postcards to selected surgical pathology reports asking three simple questions regarding customers’ satisfaction with the report. The cards bore code numbers allowing us to identify the source of, and resolve problems quickly. Customers told us that they were pleased that we were listening to them.

• Reporting our batting averages. Every month we sent the results of all our QA monitors, including our amended report statistics, to the hospital medical executive and quality committees and to the departments of medicine, surgery and pediatrics. Our competitors would not consider doing this.

• Virtual practice. I saved best for last. We finally realized we could not train ourselves to the level of expertise that our specialist customers required. Even if we could, we did not have the volume to maintain that expertise. Attracting specialty-trained pathologists to our small community was likewise problematic. And sending cases out for consultation not only incurred a certain degree of financial friction, it advertised the limitations of our practice. Besides, our customers did not want to rely on the ability of generalists to determine which cases needed to be seen by experts–they wanted all their cases examined by experts.

What did we do? In one sensitive area we added a specialist practicing 1500 miles to our west. We licensed him in New Hampshire, credentialed him at our hospital, wired his phone number into our office, and put his name on our report heads. He officially became a member of our practice. We sent to him, all designated specialty specimens processed according to his specifications, issued his diagnoses on our reports, and worked out a reimbursement arrangement acceptable to him, his partners, and us. The added value of our group perceived by our specialist clinicians dug an anti-competitive moat around our practice.

Will these strategies work for everyone? Are they practical in other practices? I’m not sure, but I hope you will let me know. They worked for us. I hope this will fuel your power to develop your own innovative solutions. And by all means, if you have arrived in Orlando for CAP’13, I urge you to drop into the afternoon HOD session and hear what your colleagues are doing to survive.

Corporate Culture in Decision Making

To the Editor

Dr Horowitz and his colleagues1 have done us all a great service in dissecting what can be for many of us, a complicated, angst-provoking process. I believe that their sage counsel goes beyond mergers and acquisitions. In one form or another, the questions they pose apply to most business strategic and operational decisions, pathology and otherwise. However, it is not always so easy to get physicians to ask themselves, let alone answer, the questions that the authors pose.

I urge readers of this article to dwell on the section entitled “Assessing the Cultures.”?1 In our experience, we find the success with which pathology groups establish a common culture to be the tipping point of strategic planning. Practice cultures must consider the diverse and sometimes conflicting needs of its constituent members. Certainly, the goals, lifestyles, and professional requirements of pathologists who are newly in practice, and perhaps single parents, are likely to differ from those of colleagues who are in mid practice and arranging college tuitions or in late practice planning retirement. Yet, groups often force square pegs into round holes by constructing a single practice model to which they require all members to conform. Unless the group establishes a common cultural platform, one that allows for the diverse needs of all its constituents, it may not be able to process into cogent business decisions the data they are laboring so diligently to collect.

David A. Novis, MD
Novis Consulting, LLC, Lee, NH 03861

1. Horowitz RE, Provizer H, Barry MJ. How to evaluate a potential merger or acquisition. Arch Pathol Lab Med. 2013;137(12):1811–1815.