As board-certified pathologists, we are among the few who have the opportunity to become a laboratory medical director. This may seem daunting to some when one considers the many duties and responsibilities as set forth by CLIA 1988 as well as the CAP’s laboratory director standard.
I had the pleasure to interview Dr. Joseph Tworek, chair of the Department of Pathology, St. Joseph Mercy Ann Arbor on the role of a laboratory medical director. Dr. Tworek is this year's recipient of the CAP’s Laboratory Improvement Programs Service Award.
1. Dr. Tworek, what experiences or training in residency or fellowship were most useful in preparing you for your role as a laboratory medical director?
Due to negligence on my part, coming out of training, I was unprepared for assuming a medical directorship. Despite being trained and certified in both anatomic and clinical pathology, I primarily focused on anatomic pathology and hematopathology largely to the detriment of other areas of clinical pathology. The only saving grace was that I was comfortable signing out a lot of material so that I could focus on CP as a practicing pathologist.
If I had to do it again, I would have taken my CP training more seriously. It's a once in a lifetime opportunity to learn not just about patient care implications but how to manage a laboratory. Emphasis should be placed on how decisions are made in each section to add or attrite full-time employees (FTEs) due to test volume changes; how are decisions made to justify bringing in a new test or analyzer, when do I validate vs. verify an analyzer, how do you reach out to clinical stakeholders on a regular basis within each discipline.
One of the most influential comments that I received when I was interviewing for my first job was from a medical director who told me that the key to success is to make yourself invaluable to your clinicians. I believe that almost all residents who are both AP and CP certified are competent in AP. But being comfortable in CP is a chance to make yourself invaluable to clinicians and your future partners in pathology.
2. Can you share some experiences as a laboratory medical director that some may consider mistakes and what did you learn from these experiences?
Always listen to both sides of the story. Often as medical director, you will hear complaints from physicians, lab employees, patients, and administration. Listen attentively with empathy, but get both sides of the story. I have made my biggest mistakes by jumping to conclusions.
3. As a new medical director, what should be done first to get a proper perspective or feel for a lab? Would one focus on the quality plan, utilization projects, or sign the paperwork as it comes? When should a new medical director begin suggesting changes?
First of all, do not turn down a chance to be a medical director—the opportunity does not come along very often. As a new medical director, the most critical task is to build trust with your lab. Get to know the employees and listen to their suggestions as a starting place to initiate change. This is particularly important if the directorship is at a new laboratory. This is a way to examine the quality plan and to introduce utilization projects. If you're moving up vertically in the same lab, do not be afraid to challenge the way things were done in the past, but do so to improve work conditions or patient safety, including improving turnaround time, or TAT.
4. You have been very successful in test utilization projects in your health system. What advice do you have for other medical directors who are asked to embark on test utilization or who may be eager to get started?
The best way to approach utilization is to think of it as a holistic process to improve lab testing in all three phases of testing: pre-analytical, analytical, and post-analytical.
- Pre-analytic: How do you get a quality specimen that is not hemolyzed or delayed with a minimal amount of blood for a test that will provide a meaningful result.
- Analytic: Is the test methodology appropriate with a turn-around time that meets expectations.
- Post-analytic: Are the report results accurate. Do comments and abnormal values display appropriately in all of the EHRs in use. Most pathologists focus on the analytic process, but we can really add value by being proactive and working on hemolysis rates, reducing iatrogenic anemia and making sure that reporting formats are clear.
A good place to start is to meet with your customers/stakeholders on a semi-regular basis such as the ER and specialty physicians. An easy method to score some victories is to examine reference lab send out testing to see if there are any tests of dubious value are being sent out. A good resource is the CAP’s testing ordering modules authored by Quality Practice Committee members. These modules provide basic background and easy strategies to improve testing.
5. You are also a leader in a region for your large health care system, what experiences can you share as a pathologist representing pathology at this level that would be helpful for others just getting started?
Being a leader at any level involves the same skill set: empathy, commitment, and follow-up. Take time to engage laboratory staff and your clinical stakeholders.
6. How do you prepare for a lab inspection?
Preparation is a continuous process. The best laboratories that I have inspected and hope to emulate have a quality plan with metrics that are actively measured and acted upon when the metrics are out of range. Don’t be afraid of deficiencies. Embrace them as an opportunity to improve. If there is a quality metric that is out of range and you are having difficulties getting resources to address it, don’t be shy about pointing it out to the inspector. Ask their advice on how they handle it in their lab. A strategic deficiency could be an opportunity to refocus efforts in addressing the problem.
My thanks to Dr. Tworek for his time as well as the Digital Content Committee for assistance in formulation of the interview questions.
Sharon K. Bihlmeyer, MD, FCAP, is Laboratory Medical Director of the Chelsea Laboratory at St. Joseph Mercy Hospital in Michigan.