Running a clinical laboratory is a complicated endeavor. Not only must trained pathologists be present to read microscopic slides to diagnose diseases in a timely manner, validate new instrumentation and be available during surgical procedures, but they must also keep the lab running to very strict and detailed standards. It’s that last responsibility—directing a lab—that is often a challenge to manage and be reimbursed for amid the busy demands of a laboratory.
It’s why Andrea Ligler, vice chair of the Department of Pathology and Laboratory Medicine at the IU School of Medicine, participated in a consulting project with students in the Graduate Certificate in Medical Management at the Kelley School of Business. One of her residents, Drew Tharp, was enrolled in the mini-MBA program and asked Ligler if there was a project his student team could tackle as part of their capstone project. Having earned an MBA herself, Ligler was enthusiastic about partnering with the students.
“I was excited when Drew came to me because students bring unbiased, fresh eyes to a problem. I had a laundry list of things we could work on,” said Ligler. “After we spoke with the team and their professor, Kim Saxton, we decided this lab director effort could be tackled in the amount of time we had, and it would be a well-rounded experience that required the students to use all their skill sets.”
The complex work of a pathology lab goes far beyond what most people learn from shows like “CSI.” While it’s more straightforward for a pathologist to get reimbursed for their work at a microscope, diagnosing disease and consulting on surgical outcomes, the extensive and detailed work of managing the laboratory also draws heavily upon a pathologist’s time, and without a clear-cut way to be compensated.
“Health systems tend to minimize lab management and are often resistant to paying for this work because it isn’t valued at the same rate as diagnosing diseases,” explained Ligler. “Laboratories that that test human specimens that produce results that will be used in clinical care have to adhere to The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations, which include federal standards. For a clinical laboratory to operate, a pathologist must hold the CLIA certificate, which makes the pathologist personally liable for everything that goes on in the laboratory. It’s a big deal, and we struggle to quantify and get reimbursement for their laboratory director oversight effort.”
This issue is not limited to Ligler’s department—it’s endemic in the pathology industry. The student consulting team began to analyze how the work is structured to determine how to better manage pathologists’ time. Ligler provided them with background articles and contact information for local and industry leaders in pathology. She remained “on call” to the team for questions that arose in their research.
“The students interviewed local pathologists; they conducted interviews internally at our academic health system and externally with community pathologists at places like Riverview Hospital. They asked a consistent list of questions to understand the scope of each practice and their complexity of cases. Together, we met with one of the top consultants in the nation, who came to Indianapolis to talk with the student team,” said Ligler. “A top billing expert worked with them, and because of their work, he invited IU to be the first academic pathology practice to join their think tank, Panel of National Pathology Leaders, to share a different approach to this issue.”
Because of their work, IU was to be the first academic pathology practice to join their think tank to share a different approach to this issue.”
The students’ research provided useful insight for Ligler and her team. A deep-dive glimpse into pathologists’ experience in her organization and elsewhere revealed a workforce stretched thin. Like many pathology labs across the country, the lab director work structure was impacting morale.
“I knew they were busy, but I didn’t appreciate the fact that our pathologists were staying until 8 p.m. and coming in during vacation time to sign off on their procedures and policies,” said Ligler. “In lab, we have thousands of standard operating procedures—everything we do is written down step by step to be replicable. They must review everything, and we weren’t giving them the time to do that. This forced them to pick and choose what absolutely must be completed, which is diagnosing disease and signing out cases. That bothered me. I learned we weren’t taking care of our people.”
IU Pathology is one of the top 10 largest CAP-accredited lab systems in the country. Ligler and the student team focused on the two most strained locations of the system and created a new column of service for the “Chief Pathologist” in the schedule. This plan reduced the lab director’s effort spent at the microscope diagnosing cases and set aside 25% of daily protected time to run the lab. This created a baseline of reimbursable effort a hospital can use to fund the pathologists’ work.
“We’ve eliminated the stress of not having time for oversight and ensuring the hospital lab runs the way it should,” said Ligler. “If someone does a surprise inspection, we won’t fail. Our pathologists can troubleshoot problems in real time. They can consult with clinicians without rush, and they can still get home to their families in time for dinner.”
Ligler added three new positions to support the new structure, and she hopes to hire six more. She says her teams were excited about the project because it gave them hope that things could change.
“Participating in this kind of project is great for the employees because they see business leaders are looking at problems in a new way—they have an interest in improving the organization,” said Ligler. “We can’t change the practice of medicine overnight, but we can work at it. If we all participate with a willingness to provide feedback and try new things, we can create change.”
Participating in this kind of project is great for the employees because they see business leaders are looking at problems in a new way—they have an interest in improving the organization.”
Ligler says the time commitment for a partner organization was appropriate for the work the student team was undertaking. Plus, having the support of a Kelley faculty member throughout the process helped everyone stay centered. Once they can produce data from the new work structure, Ligler plans to invite the Kelley students to present their findings at the next Association of Pathology Chairs conference.
Ligler not only recommends other organizations pursue a consulting project with the healthcare management students, but she already looks forward to the next one with her organization.
“This experience opened a door for us simply because of the questions these students asked and the way they approached our program. That’s been productive insight for the department,” said Ligler. “The next thing I’d like to work on with a fall cohort is implementing digital pathology and the related storage concerns. It’ll be a fun project, and this first one really paved the way.”