Q&A with Michael Astion, MD, PhD, editor-in-chief, CLN Patient Safety Focus

I am the laboratory administrator for a community hospital, and I am told we provide terrific lab services. Our hospital administration contracts our pathologists from an outside group that provides services to many hospitals. While this group speaks about the importance of lab quality, it does not provide significant help with a variety of quality improvement efforts. As an example, these pathologists don’t talk to other physicians about test utilization management issues like overusing inpatient tests, ordering genetic tests incorrectly, and allowing send outs of unusual “wellness” tests to specialty reference labs. In addition, they are sometimes absent from key hospital quality committee meetings for which we need physician representation. They have been very honest about wanting to focus on microscope-based work that they find “more clinically important,” such as interpreting biopsies, and for which they can bill. I just don’t think this is right. How might we improve this situation?

I am frequently asked various versions of this question. My first suggestion is to subtly shift your viewpoint from being right to being effective. With that as the foundation, there are three strategies for improving this problem: acceptance; using your chief medical officer or a designee as a replacement for these pathologists; and developing incentives in future pathology contracts.

Sometimes you have to accept that two seemingly opposite beliefs are actually compatible. For example, a person can be both lovable and maddening, depending on the context, and the two qualities are both true. In the majority of cases like the one we present here, the pathologists are competent and come to work every day to provide high quality services, and yet they do not want to be involved in quality improvement. This is because the pathologists are not incentivized to help with quality improvement in the clinical lab. In addition, some pathologists, from a cultural and behavioral perspective, are not comfortable in the leadership roles that you would have them perform. Does this mean they are incompetent when it comes to quality improvement? No. It means that for reasons of incentivization and culture, they have prioritized one aspect of quality—excellence in performing anatomic pathology cases—over another, helping you with laboratory quality improvement. You cannot approach this with black-and-white thinking in which you lament that the pathologists are not doing the right thing. They are doing the right thing in their opinion. It is just not your right thing.

The path to peace—and a resolution—is to accept that this situation is not likely to change. The pathologists are not employed by your hospital, they do not have incentives to do what you desire, and their approach to quality—excellence in anatomic pathology while letting you focus on laboratory testing quality—is right and reasonable from their point of view, even though you think it is not right.

At this point, you have to pivot from being right to being effective. It is easy to be right, but hard to be effective. Effectiveness means finding a new physician friend to help with lab quality initiatives while working on the longer-term issue of incentivizing your pathologists.

My advice is to prioritize the quality problems for which you need a pathologist, and then bring this to the hospital’s chief medical officer or the physician he or she designates to help you with this particular problem. You already have leverage in that you state that the lab is providing terrific service. Therefore, the lab is already held in high regard by the hospital’s medical leadership. Expect for your wish to be granted.

In general, this strategy is effective if you start by choosing problems that deal with known patient safety issues. For example, if ordering the wrong test, not retrieving test results, or misinterpreting test results have created patient safety problems—and they probably have—the medical leaders of your hospital are likely to create policies and procedures that deal with these errors. Medical leaders also will be apt to champion quality initiatives with their physician colleagues. Bringing this back to the lab, pathologists will happily comply with a request to remove useless tests or obsolete tests from the testing menu, if they know in advance that they have the backing of the hospital’s physician leadership. This is because most pathologists are tremendously competent.

Along with obtaining the help of other physician leaders, it is worth working with the pathologists to try to develop some incentives for quality improvement that could be incorporated into their next contract. For instance, pathologists can significantly cut hospital costs while improving quality by focusing on issues like decreasing blood utilization and blood wastage, and curbing test overuse, especially when it comes to tests that are not reimbursed. Financial incentives for pathologists, like incentive pay if certain quality goals are achieved, can create an environment for better alignment of your goals with pathologists’ goals.

Overall, the problem you perceive with contract pathologists can be overcome by being realistic, by focusing on being effective rather than needing to be right, and by making some medical friends in high places.

Michael Astion, MD, PhD, is clinical professor of laboratory medicine at the University of Washington department of laboratory medicine, and medical director of the department of laboratories, Seattle Children’s Hospital. +Email: michael.astion@seattlechildrens.org


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