MANAGEMENT FOR PATHOLOGISTS: ARE WE TRAINABLE?

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MANAGEMENT FOR PATHOLOGISTS ARE WE TRAINABLE?

• Elizabeth A. Wagar, M.D.
• Laboratory Director, UCLA Clinical Laboratories

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MANAGEMENT TRAINING SOME GENERALIZATIONS

• Widely recognized as an integral component of
  pathology practice
• An understanding of healthcare systems is now
  integrated into residency competencies for all
  specialties
• Training has been difficult to interface into
  standard clinical training

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DO WE REALLY NEED MANAGEMENT TRAINING?

• 64.5 of pathology residency program directors
  feel management training should be expanded
  (AJCP, 101559-63, 1995)
• 96 of community pathologists hiring new trainees
  considered skills in management useful (Hum
  Pathol 29211-14, 1998)

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DO WE REALLY NEED MANAGEMENT TRAINING?

• 15 of hr/week worked by pathologists involve
  direction and management of the laboratory
• 20 of pathologists spend gt25 of their time in
  administrative and organizational activities
• 2002 Practice Characteristics Survey
  Report, College of American Pathologists,
  Northfield, IL, 2003.

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PREVIOUS MODELS FOR MANAGEMENT TRAINING

• Mentor-based models
• Separate management rotations
• Focused curriculum
• Management lectures
• Affiliation with a business school
• AJCP, 10890-95, 1997.
• AJCP, 111156-160, 1999.
• Arch Pathol Lab Med, 116108-110, 1992.
• AJCP, 101564-568, 1994.

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LIMITATIONS OF PREVIOUS MODELS

• Sponsoring department may not have all areas of
  expertise
• Program may not be broadly representative of
  management and leadership topics
• Bias of specific departments/faculty
• Program may not be relevant to pathology-specific
  activities
• Which limitation presents the most hurdles?

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LIMITATIONS OF PREVIOUS MODELS

• Sponsoring department may not have all areas of
  expertise
• Program may not be broadly representative of
  management and leadership topics
• Bias of specific departments/faculty
• Program may not be relevant to pathology-specific
  activities!!

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MENTAL OBSTACLES

• Pathologists are different
• Business models do not apply
• I dont have time
• Unfamiliar terms
• Unfamiliar methods
• Not a high priority

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GOALS AND OBJECTIVES
To develop a management training program that
will include an overview of all the basic
management curricular elements, provide expertise
for topics not available within a department, and
present training that is relevant to the
practicing pathologist.
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IDENTIFYING THE CURRICULAR CONTENT

• Consortium of 3 major training programs in
  regional Los Angeles
• USC, Cedars-Sinai, UCLA faculty reviewed topics
• Faculty represented different types of practices,
  large county medical facility, university medical
  center coordinated with a smaller hospital,
  private medical center, (5000 to gt30,000 surgical
  specimens/yr 500,000 to gt 5 million tests/yr)

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IDENTIFYING THE CURRICULAR CONTENT

• Examined available courses
• CAP VMC (Virtual Management College), CLMA, ASCP
• Reviewed available website teaching tools for
  topics

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TOPICS IDENTIFIED

• Management principles
• Interfaces
• Personnel management
• Lab operations
• Equipment/supply management
• Financial management

• Pathology group management
• Contracts/negotiations
• QA and regulations
• Marketing, education, research
• Informatics
• Risk management

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1. MANAGEMENT PRINCIPLES

• Management is a relatively new discipline
• Peter Drucker is a founding father of the field

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MANAGEMENT PRINCIPLES

• Task/tools of management
• Attributes of the manager
• Planning (strategic planning)
• Leadership (models)
• Communications (functions, methods)
• Organizing (operations)
• Controlling (standards, performance measures,
  feedback)

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2. INTERFACES OF THE INVOLVED PATHOLOGIST

• Not routinely taught as part of standard
  management training
• Exceedingly important to the success of the
  pathologist leader

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INTERFACES OF THE INVOLVED PATHOLOGIST

• Within the pathology group
• Laboratory staff
• Professional staff (medical staff committees)
• Hospital or system administration
• Hospital services (nursing, radiology,
  purchasing)
• Beyond the hospital (medical schools, community,
  professional organizations, reference labs,
  outreach programs)

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3. PERSONNEL MANAGMENT

• Rarely taught in clinical residency programs
• Extremely relevant to pathologists who may manage
  from 10-1000 personnel in various types of lab
  settings
• Subject to state and federal statutes and
  regulations, union requirements

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PERSONNEL MANAGEMENT

• Principles of HR, job classifications and
  descriptions
• Interviews and selection
• Orientation
• Performance evaluation/promotion
• Counseling, discipline, dismissal
• Compensation, wage hour law
• Employee conflict resolution
• Labor relations and labor unions

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4. LABORATORY OPERATIONS

• Degree of involvement may vary by site
• Significant interfacing with lab staff and
  supervisors

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LABORATORY OPERATIONS

• Laboratory manual
• Subsystems, i.e. order entry, phlebotomy,
  specimen processing, etc.
• Process or workflow analysis
• Report formatting
• Signs of poor laboratory operations
• How to change/improve a laboratory

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5. EQUIPMENT/SUPPLY MANAGEMENT

• Technology assessment
• Equipment acquisition (RFI, RFP)
• Maintenance
• Supply management
• Contract services (courier, reference laboratory)

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6. FINANCIAL MANAGEMENT OF THE LABORATORY

• Learning to share-what is your relationship to
  hospital administration?
• Understand financial responsibilities of all
  involved parties

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FINANCIAL MANAGEMENT OF THE LABORATORY

• Sources of lab revenue
• Categories of lab expenses
• Who is responsible? (CAO, CFO)
• Budgets (personnel, capital, operating)
• Cost analysis and rate setting
• Financial services/statements
• Billing and collection
• Financial reporting and variance analysis

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7. PATHOLOGY GROUP MANAGEMENT

• An area unfamiliar to most residents
• How we work together as pathologists in groups
• How we share revenue and manage expenses

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PATHOLOGY GROUP MANAGEMENT

• Group organization formats
• Sources of group revenue
• Categories of group expenses
• Group structure for finance (finance committee)
• Budgeting
• Support staff
• Coding, billing, collections
• Banking and investment
• Pension funds, insurance, tax planning, audits

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8. CONTRACTING AND NEGOTIATIONS

• How to find, evaluate, and keep a job!!
  (Residency programs often fail to discuss the
  details of this process.)
• Includes specific skill sets that can be learned
  for negotiating.

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CONTRACTING AND NEGOTIATIONS

• Essentials of a contract
• Contracting with the pathology group for
  professional services
• How to find/keep a job
• Contracting with the hospital
• Managed care contracting
• How to negotiate

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9. QUALITY ASSURANCE AND REGULATIONS

• A very unique aspect of management for
  pathologists, not covered by standardized
  training programs
• Difficult to present with any entertainment value

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QUALITY ASSURANCE AND REGULATIONS

• The Qs, QC, QA, QI
• Performance improvement (PI), benchmarking
• Testing processes, SD, CV
• Levey-Jennings, acceptance of test runs
• External quality control and proficiency testing
  (PT)
• Quality control and PT in anatomic pathology

• Government statutes and regulations (federal,
  state, local)
• CLIA in the modern lab
• Accreditation (AABB, CAP, JCAHO)
• Patient safety
• Point-of-care testing
• Physician office laboratories (POLs)

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10. MARKETING, EDUCATION, AND RESEARCH

• Components of this topic also are not standard to
  management training
• Core activities for pathologists
• May vary by practice (academic vs. private, etc.)

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MARKETING, EDUCATION, AND RESEARCH

• Market research, analysis
• Product and service planning
• Advertising, sales
• Public relations
• Annual report (tooting your own horn)
• Education for pathologists and staff
• The competent physician (CME, ABP)
• Education for medical staff (conferences)
• How to conduct a meeting (i.e. Tumor Board)
• Basic principles and forms of research

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11. INFORMATICS

• Unique software for pathologists and lab services
• Challenging interfaces
• Part of patient safety initiatives
• Receiving widespread review as a means of
  improving patient care

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INFORMATICS

• Pathology an information specialty
• Hospital (patient) information systems
• Laboratory information systems (LIS)
• Internet links to physicians and patients
• Integrated patient-centered support

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12. RISK MANAGEMENT

• Unique interactions of pathologists with the
  legal system
• Role of the autopsy
• Medical examiner/coroner
• Medical malpractice cases

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RISK MANAGEMENT

• Malpractice, defining direct and indirect harm to
  patients
• Pathologists effect on the liability of others
  (pathologist as expert witness)
• Depositions, court appearance, testimony
• Record maintenance
• Interactions with risk management
• Interactions with outside legal representation

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SPECIAL TOPICS FOR ANATOMIC PATHOLOGISTS

• Medical Staff privileges
• Designing Anatomic Pathology Quality Improvement
  Plans
• Maintaining competencies in Anatomic Pathology
• Anatomic Pathology IT
• Process analysis for Anatomic Pathology

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MEDICAL STAFF PRIVILEGES

• Primary appointment process Residency Program
  Director reference, other references, board
  certification requirements, review of licensure
  standing
• Appointment renewals continuing education
  credits, references, licensure, review of
  outstanding malpractice cases, board renewals

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MEDICAL STAFF RESPONSIBILITIES

• Medical Staff Committee membership
• Review of competencies for pathologists
• Review of medical staff and hospital procedures
• Membership on other medical staff committees
  (i.e. Transfusion Committee)

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EXAMPLES MEDICAL STAFF POLICIES REQUIRING
PATHOLOGY REVIEW AT UCLA

• 1320 HS Informing Patients about Blood
• Transfusion prior to Medical or
• Surgical Procedure (GANN Blood
• Safety Act
• Systemized and Reviewed.
• 9-28-04
• 1329 HS Latex Allergy
• Systemized. New system policy is more concise and
• focuses on the assessment of allergies. Only the
  OR
• maintains a latex free supply cart. There are no
  latex
• free supply carts at the bedside.
• 6-23-05

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EXAMPLES MEDICAL STAFF POLICIES REQUIRING
PATHOLOGY REVIEW AT UCLA

• 1386 HS Specimen Exception to Pathology
  Examination
• New Systemized Policy.
• 3-1-05

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ANATOMIC PATHOLOGY QUALITY IMPROVEMENT PLAN

• Quality Management in Anatomic Pathology
  Promoting Patient Safety Through Systems
  Improvement and Error Reduction, College of
  American Pathologists
• Updated May 09, 2005
• Raouf E. Nakhleh, MD, FCAP, and Patrick L.
  Fitzgibbons, MD, FCAP, editors

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ANATOMIC PATHOLOGY QUALITY IMPROVEMENT PLAN

• Designing a Quality Improvement Plan
• Regulatory Compliance
• Strategies for Error Reduction and Prevention in
  Surgical Pathology
• Defining and Handling Errors
• Quality Improvement Plan Components and Monitors,
  Pre-analytical, Analytical and Post-analytical
  Errors, Benchmarking
• Quality Management in Histology,
  Immunohistochemistry, Cytology, and Autopsy
  Pathology

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ANATOMIC PATHOLOGY COMPETENCIES

• Introducing the resident to maintenance of
  competencies
• Role of CME
• Director of Surgical Pathology, review of
  competencies
• ABP recertification for all resident graduates
  receiving time-limited certificates (starting in
  2006)

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ANATOMIC PATHOLOGY IT

• The Scope of Pathology Informatics
• Desktop Computers Hardware.
• Desktop Computers Software.
• Networking and the Internet.
• Databases.
• Pathology LIS Relationship to Institutional
  Systems.
• Evaluating Anatomic Pathology Information
  Systems.
• Digital Imaging in Anatomic Pathology.
• Video Microscopy and Telemicroscopy.
• Electronic Interfaces and Data Exchange.
• Case Identification by Diagnosis.
• External Regulations Pertinent to LIS Management.
  
• Pathology Informatics and the Future of Medicine

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ANATOMIC PATHOLOGY IT

• Practical Pathology Informatics Demystifying
  Informatics for the Practicing Anatomic
  PathologistJohn Sinard
• Softcover 410 pages ISBN 038728057XSpringer-Ve
  rlagOctober 2005Price 69.95

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PROCESS MAPPING FOR ANATOMIC PATHOLOGY
(or, learning a little
geometry.)
Decision
point?
Input or output
Step or task
Primary process
(must occur)
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PROCESS ANALYSIS FOR ANATOMIC PATHOLOGY

• Why do we care?
• Workflow analysis for Anatomic Pathology
• Appropriate use of personnel in AP
• Anatomic pathology platforms
• Ventana, DakoCytomation, LeicoMicrosystems

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REGIONAL MODEL FOR MANAGEMENT TRAINING

• Six residency programs USC, Cedars-Sinai, UCLA,
  UCI, Wadsworth VA, Harbor-UCLA
• Alternate presentations between 3 sites on a
  monthly or bimonthly basis
• Videotape sessions for program directors
• Assemble hand-outs as a syllabus

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REGIONAL MODEL FOR MANAGEMENT TRAINING

• Keys to success include
• Identifying speakers from other disciplines that
  are familiar with pathology
• Providing a congenial meeting of peers
• Food!

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WHERE TO FIND SPEAKERS

• Human resources departments
• Legal representation for departments or
  healthcare institutions
• Accounting firm representing medical groups
• Review VMC speaker lists, PPM speakers, ASCP for
  pathologists specializing in management
• CLMA representatives for lab operations
• Hospital contracting office, COO, CFO

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WHERE TO FIND SPEAKERS

• Combine speaker invitations
• with other programs, Grand
• Rounds, CME lectures

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MANAGEMENT TRAINING SEMINAR SERIES

• Evaluation forms collected at 11/12 sessions
• Nine question evaluation form graded on a scale
  of 5 (excellent) to 1 (poor)
• Sites alternated between USC, UCLA, and
  Cedars-Sinai

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EVALUATION FORM

• Lecturers knowledge of subject
• Lecturers ability to communicate information
• Usefulness of material
• Knowledge prior to the seminar
• Knowledge after the seminar
• Educational methods used
• Sufficient time for discussion
• Value of handouts
• Overall evaluation
• Comments

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RESULTS

• All responses, (other than the 2 questions re
  the knowledge component) were averaged with an
  overall score of 4.66
• Averaged 13 evaluations per session, 141
  evaluations total received
• 281 resident attendees
• Value-added increase was 1.5 for value-added
  questions

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SEMINAR VALUE

• The topics receiving highest overall scores
  (gt4.8) were those involving finding a job,
  interfaces, and pathology contracting and
  negotiations
• The topics receiving lower overall scores (lt4.5)
  were related to quality assurance and regulations
  and insurance/managed care contracting

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RESULTS

• Seminars were best attended by PGY2 and PGY3
  residents
• PGY4 residents least likely to attend
• Fellows, faculty, and senior residents beyond
  PGY5 had excellent attendance
• Use of videos off site confirmed by 4/6 program
  directors

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SOME ADDITIONAL THOUGHTS..

• Why were PGY2 and PGY3 residents our most
  frequent attendees?
• PGY2 and PGY3 residents are over the initial
  learning curve
• Not yet involved in board preparation or job
  searches
• Valued the peer group interaction

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ADDITIONAL COMMENTS..

• Questions frequently centered on issues related
  to the job search or the experience of new
  pathologists
• A complete syllabus was provided to each program
  director at the end of the series to use as an
  educational tool
• Maybe they just liked the food?

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ARE WE TRAINABLE?

• Pathology residents show significant interest and
  a measurable knowledge increase
• Topics should be specifically modified to
  incorporate pathology/lab management as compared
  to general management approaches
• Practicing pathologists may have a more
  discriminating focus than residents, i.e.
  billing/coding issues
• Ask outside professionals who understand clinical
  laboratories to present their expertise

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THANKS

• Dr. Richard E. Horowitz, Course Organizer
• Dr. Wes Naritoku, LACUSC
• Dr. Ellen Klapper, Cedars-Sinai Med. Ctr.
• Dr. S. Renner, Wadsworth VA LA
• Dr. Marcia Cornford, Harbor-UCLA
• Dr. Scott Nelson, UCLA
• Dr. Jane F. Emerson, UCI

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THANKS

• Ms. Marilyn Sharpe, Vice President, HR,
  Cedars-Sinai
• Lee Hilborne, M.D., Quality Assurance Director,
  UCLA
• Mr. Jack Bierig, Esq., CAP Counsel
• Richard J. Hausner, M.D., CAP Governor
• Ms. Francine Chapman, Assoc. Med. Director,
  Contracting, UCLA
• Don Harper Mills, M.D., J.D., AAFS

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THANKS

• Clive R. Taylor, M.D., Ph.D., Chair, USC
• Jonathan Braun, M.D., Ph.D., Chair, UCLA
• Stephen Geller, M.D., Chair, Cedars-Sinai

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THANKS