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?
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.
Here are five key responsibilities of the laboratory medical director.
- 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.
- 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.
- 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.
- 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.
- 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.
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.
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