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 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.