Transcript: Community Laboratory Perspective

Transcript

Triona Henderson: Good afternoon, my name is Triona Henderson. I am Clinical Pathologist and the facilitator for this ECHO Model™ pilot project and I extend a warm welcome from the Division of Laboratory Systems at the Centers for Disease Control and Prevention in Atlanta, Georgia. We also welcome back many participants from session one. Thank you for joining.

The topic for this interactive web discussion today is Community Laboratories Perspective. Our subject matter expert is Heather Duncan, the Manager of Microbiology in the Department of Pathology and Laboratory Medicine at Vidant Medical Center in Greenville, North Carolina.

Before introductions and the presentation, I want to briefly mention some technical details related to our ECHO sessions. Please use the video capabilities of whatever device you're using for this session. There is an app available on cell phones to view the live content.

Though we want to encourage discussion, please mute your microphones when not speaking. If you are experiencing technical difficulties during the session, please send the private chat to Johanzynn Gatewood, labeled as DLS ECHO Tech. She will do her best to respond to your issue. If you are connecting by phone only, please rename your phone number to your name and institution. And please announce yourself by name and state when beginning to speak.

During the didactic portion of today's session, our subject matter expert, Heather Duncan, will be using Poll Everywhere to enhance audience engagement. Please have your cell phone or another browser tab open to participate today.

Finally, part of designing relevant sessions is looking at your evaluation responses. We would like to encourage everyone to complete the post-session evaluation. P.A.C.E ® credits are being offered for this session and all subsequent sessions. Either a Certificate of Participation or a P.A.C.E ® certificate will be issued upon completion depending on your selection. If you have additional comments, please send a private chat message directly to Johanzynn, or email directly to DLSECHO@cdc.gov.

Briefly, how do these ECHO sessions differ from other sessions? These sessions are different from expert lecture teleconferences or webinars in the discussion of cases or clinical laboratory challenge being the main feature. Subject matter experts hope to share some of their solutions that will be translatable to all of you in your individual laboratories. These ECHO sessions are focused exclusively on clinical laboratories in the United States and the US territories. Once again, we value the discussion amongst all of you that ensues and want to encourage you to share your own experiences and challenges on this topic. We thank you for your interest and participation.

Here is an overview of the process. There will be a case presentation by the subject matter experts. Then I will summarize the case, we will have clarifying questions to the subject matter experts, and then we'll open the floor for ideas and shared experiences with comments by our SME. We'll have closing comments and reminders, and then we'll adjourn.

Today's session is being recorded. If you do not wish to be recorded, please disconnect now. Closed captioning will be provided for this session. Find the link in the chat box. A transcript of this session and the slide deck will be provided via email to registered participants.

Here is Heather's bio. Heather Duncan is the Microbiology Manager at Vidant Medical Center in Greenville, North Carolina. Vidant Medical Center is a 974-bed level one trauma center, regional referral hospital, and is the flagship hospital for Vidant Health. This is a comprehensive health system made up of nine hospitals that serve 1.4 million people in 29 counties in the rural eastern portion of the state.

Heather has a diverse laboratory background that spans industrial food safety, clinical and regulatory compliance. Before joining Vidant Medical Center, Heather successfully established a high complexity laboratory for the Department of Veterans Affairs as the chief technologist. This was her second laboratory setup. And she had previously established a food microbiology laboratory for Heinz Frozen Foods.

Her passion for quality and inspection inspired her to become a Certified Quality Auditor and serve as a CLIA surveyor. Heather enjoys travel, reading, and boating in her free time. Now we'll invite Heather to describe her experiences as a laboratory manager and her use of a multidisciplinary team approach. Please be thinking about a similar situation you've encountered. Offer your questions during the discussion period. As you think of these questions, include things that have worked and things that should have worked but did not. Heather, I hand it over to you.

Heather Duncan: Good afternoon. I'm so excited to be presenting here today from the community laboratory perspective. When I started working on my material, it was incredibly difficult to select a topic because, I mean, how do you choose a broad topic that's going to appeal to all the diverse labs that we are discussing here today?

So, when I narrowed down my subject, I decided it was– while the subject is important, it's more important to look at the process that we followed in our approach. So, while we're working through this case study, just keep in mind that it's more important, even though that we're talking about a point-of-care process, that we're focusing on the process that we followed and not so much about the point here. So, my goal today is that it's very interactive and that we're just starting off the conversation.

So, keeping that in mind, we're going to start off with an icebreaker. And I want to talk about our resource gaps. And I want to get some feedback from the participating labs about what our resource gaps are in the community.

So, this is an interactive exercise. We're going to be using Poll Everywhere for this exercise. So, it's confidential. And so only the responses will display. So, please be candid with your responses.

You'll be able to join by web or by text. So, if you're joining by web, please go to the link here displayed, PollEv.com, enter the H-E-A-T-H-E-R D-U-N-C-A 104, and respond to the activity. Or text H-E-A-T-H-E-R D-U-N-C-A 104, and text in your message. And I'll give us everybody a moment to join because it does take us a moment to join.

And for those people who aren't familiar with the word cloud, the responses we're going to give here are going to be– I just would like to know, what are your resource gaps? There are no restrictions on how many responses you can give. So, list as many as you think are important.

And as the words display in the word cloud, the more frequently a word is used, the larger that word will appear. So, it's going to have more predominance, and it's going to be more important or have a larger prominence in the word cloud. I hope everybody's had time to join the activity.

That is taking a minute to display. All right, there we go. And there is a little bit of a time gap. So I'm giving this just a few more seconds for this to populate because I can see from my technology that it is populating a little bit faster in the application than it is on the slide. So we'll just give it another moment before I lock the slide here.

I'm going to go ahead and lock our responses. And hopefully, it will refresh here in a moment. That's the fun thing about technology. Sometimes it– well, I'm going to give it another moment to hopefully populate. But I'm going to just read off what I can see and maybe you can't see as well.

Workforce, money, time, and support were the largest words in our resource gap word cloud. And I hope that it transfers over. If not, you'll see it in the slides that come over that are sent out after the presentation. Workforce, money, time, support. And access actually came over at the very last second. So, as we move forward, I think that the process that we followed and the problems that we faced in the study that we're talking about actually addressed and dealt with some of the same resource gaps.

So today, we're going to talk about a point-of-care program. And the before is, we were looking at working with more than 100 point-of-care glucose testing personnel. We had one ancillary testing coordinator who also handled our quality programs. So she was wearing many different hats, not just ancillary testing. And, also, working with two different sites of care which were two hours apart. So there was also distance that we were dealing with, with these two sites up here. We're in rural areas. So there was quite a bit of distance between those two sites.

So within this program, it was the lab's responsibility to schedule the competency assessment appointments with the users. So what we saw is that we had skipped appointments which then led to expired access because they skipped the appointment and missed their competency assessment window. And their access would expire. Then we'd see people who shared barcodes because they– their barcode would be expired that they used to test. And then we have a compliance problem with the sharing a barcode. Or they wouldn't be able to test their patients, and we'd have delayed patient care, which are all pretty big problems.

We had users that maintained their own competency, copies of competency documents for end-of-year reviews, which they needed to– for their annual performance appraisal for the– our internal process. And they had a lot of difficulty keeping up with these copies. And the laboratory held these paper copies. So we had lost documents.

And then there was an end-of-the-year rush where multiple users were showing up unexpectedly. And they had to have their copies of the documents or they wouldn't be able to get their performance appraisal. They had to have it.

So then there's this crazy rush of documents and copies and trying to do everything for them. So this was a very inefficient process, a lot of stress on the users and a lot of stress on our laboratory, as well, to try to– we felt this push to really want to help, but very difficult to stop your workday, very– just a mess.

We also found, as we worked through this process, there were two different competency forms and two different processes for these users that were performing point-of-care glucoses. So they were performing not just a laboratory competency; they were also performing a nursing competency. So they were essentially being competency assessed twice for the same process.

So we had a duplicative process. So no wonder the users were– they didn't know if they were coming or going because they were doing this twice. And they had two different copies of paper to keep up with. And so the process between lab and nursing also was very inefficient with time.

So we had a one on one training with the nurse educator and a one on one training with an ancillary testing coordinator. So we have double time and effort being placed with each user.

Before we– I want to do another little activity. Hopefully, our connection is a little bit better. For this one, we're going to talk about barriers to process improvement. So I'd like to know from the group what our barriers to process improvement are.

I want to talk about the process we follow for process improvement. A lot of times, we don't start a process improvement. And why not? What prevents us from improving a process, or why is it hard? Because it is. It's really hard. It's not that we don't want to do it. Why can't we do it?

I'm going to– this is not a word cloud. This is a– I guess I'm going to read them off since it's not transferring. They'll be in the slides after. Communication, not a culture of learning, administration, management, culture, time, education, system, culture, culture. Time, time, time, staff buy-in, commitment, team assembly, resistance to change, protocols, techs set in their way. It looks like maybe we've reached an end. So I'll lock this activity. And the answers will be on the slide at the end of the presentation. And I'm sorry that connection must have slowed down with so many users. So didn't work quite as I intended.

The process that we went through to make the process better. It was so difficult. We were constantly in firefighting mode to try to keep this process under control.

The first step– and I want to talk through four different kind of pillars of how we made this process a little more manageable. First thing is evaluate. So we looked at, are they non-value added processes? And were processes based on tradition rather than function?

We've always done it this way because you get very comfortable. We've always done it this way. So this is the way we have to do it. So we found that we had duplicative competencies as we've talked about, inefficient record keeping. And these are non-value added processes.

And then, we had users in the system that were no longer performing testing. So they had always performed the testing. They'd always been– had competency assessed.

When we actually scrubbed the list, they hadn't performed an actual patient test in over a year. So they didn't even really need to keep up that competency. They had just always done it. So we scrubbed those lists.

And I'm going to talk about; I'm calling them seize the moment opportunities. So at the same time, we looked at some other processes along the way. So we also looked at some of the other point-of-care user lists.

So another platform that was available was that the i-STAT list. We scrubbed that list and looked at the same thing– are users being competent assessed but not actually performing patient testing– and scrubbed that user list by over 90%. So that reduced tremendously that workload of trying to maintain those competencies, not just for the users but also for the assessors. And then you can also– there's further downstream effects of reducing cost. All kinds of good things come from that.

And then also looked at how those analyzers were being used, because there was another frequent refrain that we heard of and complaints of not enough analyzers to go around. We need more analyzers. Don't have the money to buy more analyzers.

So we actually looked at not just users, but how many tests are being done, and are they being used based on tradition and function? We've always had an analyzer here. Well, are you using it? Are you really using it?

How often are you using it? Can we just have it there for certain period of time? How is it being used?

So we were able to look at reallocating analyzers based on clinical need rather than tradition. That's a whole other process, but I just want to talk through some other things. You don't have to just focus on, we're only looking at competency. But there's also some other trickle down effects of other things that you can pick up along the way, some low-hanging fruit.

Collaborate. So we reached out to stakeholders in the process because we're not working in a vacuum. We all need each other. With the ancillary testing, you're working with a lot of other groups.

So we talked to the end users. The end users were suffering, too. It wasn't just laboratory that's suffering. The end users were having a hard time because they're trying to schedule these competency assessment appointments in the middle of their work day. They're trying to run out a clinic. They've got patients in front of them.

They weren't missing appointments because they just didn't want to do it. They felt that pressure of I've got to take care of the patient. And the patient's right in front of me. Clinic's running over. What do I do? And so then, they're just– it just was not a good process for the end user either.

So as we talked to them, it was, well, what would work better? How can we make this better for you? What scheduling would work better?

Are there times during the day or during the week you have scheduled educational periods that we can fit this in where it's not– and we're always in firefighting mode. We're firefighting. We're reacting instead of being proactive about this. How can we schedule this?

And we talked to nurse managers because we needed to have their buy-in. We needed to work with them on this process because when we did have noncompliance, we needed the nurse managers who were, for the most part, the supervisors of the end users to be involved in that process, because laboratory didn't have the authority in many instances to make decisions or to enforce.

You didn't come see us. We can lock you out. You don't have access. But to have real authority, we didn't have that authority. So we needed to involve the people that really had the authority to make decisions and to follow up with the users in a real authoritative role, not just the big partners.

And then nurse education because they really had a 50% stake in this process, and they held the key to the other half of this competency piece. And what are some other seize the moment opportunities? I want to talk about collaboration a little bit because I feel it's so important.

Collaborating and trying to work with other areas, when you're building your network and you're collaborating, if you want to try to build a network, volunteer for committees. And it doesn't have to be something where you have a lot of work. It can be fun committees.

But if you start getting outside of the lab, you start meeting people and meeting people in other areas, you start knowing who to go to. You have a face. They know your name. So when you need something, you've already made that reach out. And it makes it a lot easier to ask for something when somebody already knows who you are.

Celebrate with other groups. When they have a professional week or they have a milestone, just that congratulations. Happy nursing week. I know lab can be a little bitter sometimes about some of the other professional weeks. But it does. It goes a long way to say, we really appreciate you. Let's celebrate together. And sometimes that gets reciprocated because it makes people realize we're here. We're partners. We're working together.

And we have to put the hand out, too. We put the hand out, a hand reaches out and grabs it. So we've got to– a handshake takes two.

And talk to people that walk through the department, work in the department. I make it a practice. If somebody's running the department, I just talk to them for a few minutes. And I'm really surprised at the information that I find out just by somebody who's walking through the department.

I'll never forget, I had been waiting for and actively working trying to get a fax machine connection hooked up. It needed a port. And I know that sounds silly. Why are you waiting a year for a fax machine? Fax is outdated anyway. But it's just one of those things.

And I had an IT, some IT folks working in another project in the department. And I was just casually talking to one of them, trying to get my project moved along. And he said, well, you don't need this.

You have an e-fax program. You just have to go and download it. And I said, what? And it was amazing, the most amazing thing. My mind was blown. It was so exciting because I could do it from my desktop. I downloaded it on all the computers. It automatically put my cover sheet on there. Nobody knew about it. But that solved my problem.

And I was able to send that out to other department heads in my system. And they were able to use that solution to solve some other problems that had been a major barrier for some other projects. But that was just by a five-minute conversation from somebody walking through my department. So just take a few minutes to talk with somebody. You never know what you're going to find out. And it doesn't take long. And you've already built those relationships.

So you have somebody's name. You didn't have their name before. You've made that connection. And it's just really important.

Don't wait until you need something to build your network. And I call that being a sometimer. Don't be a sometimer.

And sometimes it's inevitable. You don't know who you need till you need them. But it just really helps when you've already laid that framework and you've made those connections, and you have those relationships ahead of time if at all possible.

So delegate. When I want to talk about delegating, this is where I just want to say, is the right person doing the right job at the right time? So have you got the right people in the right roles?

So for this, with the nurse managers, we looked at compliance. So when we talked to the nurse managers, we said, hey, can you help us with the users? When we start looking at this process, can you help us follow up with them and make sure when we make these appointments, and we looked at our scheduling, that we're making sure they come to their schedule on time?

Because it's really hard for us to enforce this. We don't have any real authority over them except to lock them out. And that has bad effects down the road. And with nurse education– and they were agreeable, and we looked at this whole process. Nurse education took over the electronic training program. They already had access to electronic training. So we looked at building this electronic training our training program into an electronic training program. They had access. So they took over that piece. So we delegated that piece to them.

And with laboratory, the quality piece still really felt belonged to quality. With the linearities, proficiency testing, that sort of piece still really solidly fell into laboratories. So we started looking. What pieces really belong to what group? And who would be the right person to do the right job at the right time in this process as we try to start delegating some of these responsibilities?

With that, consider, with delegating some other tasks, if you have a resource gap, let's say, like, lab directors, if have an off-site lab director, or if you have very [INAUDIBLE] your pathologists, or you're just overwhelming your pathologist or your medical director, consider delegating some of those repetitive tasks using your letter of delegation and making sure it's a delegatable task from them. But delegate some of those things. If they're just overwhelming your lab director, delegate them away.

If you're a 24/7 operation and you're only– you're overwhelming your first shift– and I've seen that a lot– make sure you're including your new or off shift techs and some of these validations, quality task, inventory management. Everybody's very capable. Make sure you're spreading all that love around.

And then are you having technical staff who are very valuable perform administrative tasks that can be delegated? Or can you just streamline that and just do away with some of these administrative tasks? But think about, are they the right people to do this job? Is that what you want your technical staff to do?

And last, when we talk about elevate, are there opportunities to capitalize on your existing technology? So if you can use technology to do some of that heavy lifting, use those programs in any kind of process control that you have whenever possible. So we used user lock out in the program that we have to drive users to a new training date, which I'll talk a little bit more about in a minute. User lock out to enforce non-compliance when we didn't meet any kind of training dates. Electronic registration for competency courses, and electronic training or e-learning programs, and electronic tracking for course completion.

And then some other opportunities to think about, using electronic signatures. Again, if you have an off-site director or other off-site leadership positions, really cut some of the paper shuffling. Electronic signatures are a wonderful, wonderful thing.

E-fax, I just talked about that a little bit. You don't have hard equipment. It's more secure.

And then, again, QC lockout. I've seen so many platforms that have a QC lockout function, and it's not being utilized. It's a way to make sure you're enforcing your compliance or maintaining your required QC period. So I really encourage, any time that function is available, use it.

And even if someone's told you– and I caution you, just don't use word of mouth and hearsay. And just investigate because it's very often available. And I'm a big fan.

So let's talk a little bit about the point-of-care program app. Again, we still have the same, give or take a few number of users, the same ancillary testing coordinator. So we put our training program. We scheduled it in electronic training system, our e-learning program. So instead of making one on one appointments, we put the– we scheduled the training program in our e-learning system.

So this was enforced by our nurse manager, who was the direct supervisor of all of our users. That took the onus away from the laboratory. So, in this case, it took that stress off of the lab, and it put the right job on the right person to enforce that. And then the users were a little bit more in control of their scheduling through the training system. And then the heavy lifting was done by the electronic scheduler.

We drove the scheduling and the training sessions to a very predictable scheduling course. So it was during a two-month period at the beginning of the year. And we scheduled them during scheduling periods that were already pre-assigned when there were no clinic sessions so that this was time where the users had a very focused time to spend on education.

So there were no clinics where they had to run out and try to make time. These were set up in group training sessions. So this was a lot easier for users to be able to go and really focus on their training.

The training records were maintained in the electronic system. The original paper was retained by lab. Training record was visible for the users, educator, and supervisor. So no more end of the year paper shuffling, last minute, I've got to have it for my end-of-year evaluation. And that also allowed there to be tracking for compliance so that the nurse manager could enforce if we had noncompliance.

We had a single unified competency document. So nursing, the nurse educator, and the laboratory look together, work together to unify those competency elements into a single document and a single training program. So all the duplicative elements were removed, and required elements were combined. And then, that multidisciplinary training program was administered by both nurse education and lab together.

So all of the subject matter experts were together in one group. The users were together in these group trainings. And it was a very synergistic, very high-quality training program where the users were able to ask questions, all of the subject matter experts were able to answer those questions, and it was much– a very, very positive experience. So with the predictable training cycles and the high-quality learning environment, everybody was very happy with the end result. The planned process enhancement opportunities at the end of the process were we started with one preliminary, our site of care. So the plan was to add the second site of care and then also to build the written quiz into the electronic training system.

Just want to give credit to the team because you can't do this by yourself. So Lauren Tyson, Dee Dinsdale, and Nancy Leggett-Frazier, who's not pictured. And the really fun thing about this is this process won a Nursing Quality Best Practice award, which is fun because you tend to think of this as a laboratory process. But it did win a Nursing Quality Best Practice award. So that's a really fun thing.

Just want to thank you for your time and attention today and give you my contact information in case you ever want to collaborate on anything in the future.

Triona Henderson: OK. For everyone who has either come in late or just to recap your presentation, so you described a multidisciplinary problem-solving approach with four key foundations. So you evaluated, collaborated, delegated, and elevated.

So you evaluated a process of point-of-care testing and looked at a redundant process, competency inefficiencies, and record keeping. You then collaborated with stakeholders in the process that existed. And you really collaborated with stakeholders outside of the laboratory system.

Then you developed a plan to delegate tasks, that the right person was doing the right job and at the right time. And then you finally elevated the use of existing technology wherever possible, which for me is very important because smaller labs don't usually have the capital to purchase newer technology. So you basically used what you had at hand, right?

Heather Duncan: Absolutely.

Triona Henderson: So if you can go– I just have a clarifying question, but just a deeper dive question. Since you were working with so many moving pieces and so many stakeholders, can you give us a specific example of a barrier that you encountered while modifying such a complex workflow? And not complex because it was complex, but it was complex because it's many duplicative processes.

Heather Duncan: So we did have a few exceptions where we offered quite a few training sessions. And they were predictable and during pre-established training periods that the users would have. But we did have a few exceptions that just seemed to not be able to make it to those sessions. So we did make sure that we redirected those exceptions through the nurse manager so that we were handling things through the chain of command that we had established and that we still wanted to make sure that we had delegated to the nurse manager. And that was the person that was ensuring compliance.

And then we also found that we had to add additional training sessions on. So even though we thought we had predicted the right number of training sessions, we still found we had to extend. So even though we predicted we would be able to complete it in two months, we had to add an additional month, an additional two to three training sessions beyond the period we had anticipated.

The third thing that was a little bit of a barrier was, originally, the nurse manager did not have admin access to the e-learning program to be able to monitor the training records attendance. So she had to be provided those manually. So that created some stop gaps or some barriers in the process so that we needed– we had to remedy that.

Triona Henderson: Perfect. Thank you. I just wanted to bring back up a question from our session one, our kickoff, about communication between the teams that somebody had brought it up. And we said we'd leave it for session two.

I know you described this process. Are you consistently involved in collaborative decisions involving laboratory testing? And do you have any advice for laboratory teams out there who are trying to work on this collaborative effort in general around laboratory testing?

Heather Duncan: Sure. I'm absolutely involved, I think daily, on collaborating with groups outside of the lab on decision making. I think now my role here is– tends to be a little more specialized because I am microbiology. So there are certain groups that I'm more involved with on a day-to-day basis and maybe less so with less specialized groups.

But I think the most important thing to me is five minutes of face time is more valuable than 50 emails. So if I get the opportunity to have a face to face meeting, I will take that opportunity if it's reasonable. And I know it's important to be protective of personal time because time is so valuable. But trying to make that personal connection at least once.

A phone call– sometimes email is really important. And it's helpful to capture things so that you have documentation. And you need that quick connect– email– I don't know– document trail back and forth. But to make connections, you really want to collaborate. Personal connection is the most important thing. So just walk outside your door if can. If you can't get to them personally, pick up the phone. And that is the best way to make a personal connection and start creating those relationships.

Triona Henderson: Perfect. So now we will open up for ideas and questions from the audience. We have two questions ready in the chat box, but we would recommend– highly recommend– that you use your microphone and introduce yourself. And you could possibly turn on your camera when you're speaking to us. So the first question to Heather is, have you attempted to roll this out for physicians that use point-of-care testing?

Heather Duncan: So the pilot was for any user for point-of-care glucose. And then it was for a second site. I have not tried to roll this out for physicians, but I see no reason that it would not work.

Triona Henderson: Question number two for you, Heather. Did you create your own training program, or did you find them somewhere?

Heather Duncan: We created our own training programs.

Triona Henderson: Thank you. Can actually physically unmute yourself and introduce yourself. So we just muted everyone back. So you'd have to manually unmute yourself, so individual, because there's too much feedback.

Jim Crawford: Hello. This is Jim Crawford from Northwell. What's on your list? You presented one process improvement. And what sort of things are you aiming to tackle?

Heather Duncan: So I'm looking at streamlining some of our test processes right now, looking at our procedures, working with quality at looking at some of our internal specimen quality processes, and working with infection control. So I'm looking at– may mean some next gen. This is a few of our projects right now.

Jim Crawford: And what sort of tasks come to you from institutional stakeholders, hospital administration, nursing, medical staff?

Heather Duncan: Tasks. As far as daily tasks, our process improvement tests?

Jim Crawford: Actually, so the question I'm asking, I agree with you completely that the engagement outside the lab is really central to what you do. One epigram that comes to my mind is, make your friends before you need them, which you do by walking about and that face time. The question I'm asking is, in the realm of quality and process improvement, on the one hand, you have your own laboratory initiatives, things that you feel you need to do to serve the institutional mission. And on the other, there are pain points or visionary aspirations on the part of your institutional stakeholders. And I'm curious as to what the dynamic is between your own self-generated strategic activities are and those that the institution comes to you and says, can you do this?

Heather Duncan: Well, I try my best to make my personal– what I think needs to happen– fit within the institutional mission. And that's the way I try to sell it. And usually those things line up. They usually align. And when I'm asked to do something by the organization, and it is an organizational imperative, I think it's important that we make sure that we're meeting that mission.

So it's always a balancing act. I think that's what we're talking about here, is when you look at your resource gaps in our time and our things that we have to do every day, it's always a balancing act and trying to prioritize. But I think that, when we're looking at our organization and organizational needs, I think that organizational imperatives need to come first. But everything is patient-centric. So anything we're doing to make sure that we're improving patient care and meeting our mission is important with just, how do we prioritize?

And sometimes it's– is it low-hanging fruit? How quickly can we implement it? And sometimes, some things are going to take a long time. And it's something, you can do something very quickly with a very short outlay of resources, then you may be able to make some of those moving parts go at the same time. It's a very small cog in the wheel, and they've got a very large cog in the wheel, and they can all turn together.

Jim Crawford: You anticipated my second question, which is resourcing. An example is a new surgical oncology practice is joining your institution. And you need to prepare for the laboratory testing, the blood, the microbiology, whatever it is their needs will be, and in essence, be part of the strategic planning for onboarding new practice needs as opposed to being reactionary and behind the curve.

Heather Duncan: Well, I mean, I think it's really great if you know they're coming ahead of time and what their needs are. And I think that's best-case scenario so that you can be proactive with anticipating the needs. I think in practice, often you find out after they're here. And you're trying to run to catch up.

Jim Crawford: That's why I'm asking. It takes me out in the hallways and getting– finding out what people are thinking, or snagging them as they walk through your hallways. I love your example of, if someone's walking through your department, find out who they are and what they know.

Heather Duncan: Sometimes that's the best way to find out. And I found that our housekeeping staff know everything. So they—

Jim Crawford: As do the runners.

Heather Duncan: Absolutely.

Triona Henderson: Other questions for Heather or general discussion points?

Jim Crawford: Well, it's Jim Crawford again. And I've been musing, as I listen to you, about the relationship of laboratory administration and laboratory medical directorship in the community hospital setting, because the questions I was asking you in terms of knowing what's going on in the institution I would say fall heavily on the medical director. The medical director is going to sit on the medical board. Medical director is hopefully in daily conversation with the provider community for your hospital and ambulatory environment.

And the ability of your medical director to bring intelligence back to the laboratory is huge. And without putting you specifically on the spot, over the course of your career, could you comment on the symbiosis between laboratory management and medical directorship? It's a leading question because I believe very strongly in it.

Heather Duncan: Well, I think it's very important to have a strong relationship between your management, and your medical director, your pathology support. I don't know. I've always looked at my position or my job is to be very protective of my laboratory document medical director, my laboratory director, and to– I don't know– lead the charge a little bit, and to make sure that I'm protective of that resource. My medical director can't champion for me, and for my group and my team, and for laboratory as a whole if we're not communicating well. So we have to work well together.

And I have to be protective of that resource and not wear that resource out so that my medical director is able to do what we need that my medical director to do. And I've always felt like that– the better that communication is and better that relationship is, the better we're able to each do our jobs and have the things that we need, and the resources that we need, and the support that we need on both sides.

Jim Crawford: So do you find– I'm a pathologist. So again, this is a leading question. Do you find that medical directors are coming in with the requisite skills to be organizational advocates and organizationally skillful? Because this is a lengthy discussion in the realm of graduate medical education for pathologists, is if they're not gaining the experience required to be medical directors.

And I would argue that a community hospital medical director is far more exposed than a more sub-specialized medical director in a large tertiary or quaternary hospital. For a community hospital, the medical director needs to have skill sets that really encompass a much broader swath of organizational skills, let alone expertise. And so this is a source of anxiety in the realm of pathologist training.

I'm curious, in your experience, when people actually do show up to be a medical director, do they have the requisite experience? Or is this something that, when they come to you, you're still seeing the gaps that we talk about in our training programs?

Heather Duncan: Well, I think it's hard to generalize. I think that's a pretty broad generalization. Part of that is I think that it's very overwhelming. So I think workload has a lot to do with it, too.

So I think sometimes, the workload can be so overwhelming, it's hard to do everything that needs to be done as a medical director, especially in a community setting where there's– you've got a patient workload and we've got all these other things that need to be done from a director standpoint. I don't know. From my experience, I think it's hard to generalize, because it's very different from person–

Jim Crawford: And I recognize that I may be putting you on the spot. To speak for myself, having actually fairly recently served as a medical director in a community hospital, that both from the standpoint of recruitment, and I can assure you myself being in the hot seat, it is a very demanding job with regards to the requisite expertise. And I'll not compliment myself, because I think I came in underpowered.

And going back to my prior question, the symbiosis between laboratory management and medical directorship is absolutely huge, number one. And number two, finding good medical directors from recruitment standpoint can be successfully done, but it's a real challenge. These are very special skill sets, and people with experience are of high value. Ideally, even within a community practice setting, younger people can be mentored. And I'm a big believer in mentorship. I would argue the same for laboratory management. Mentoring your supervisors to be managers and eventually your successor. The career mentorship is a critical part of having a successful community hospital operation.

Heather Duncan: I think this might be a question for the rest of the community participants actually because I think we have a broad range of community hospitals represented. So they may be able to speak from some other experiences other than mine.

Triona Henderson: And that was going to be my question. Is anyone on the line out in the community experiencing or noticing these gaps, either with your PhD or MD medical directors coming in and dealing with the low resources or low capital, not being able to do region rentals and all the other things that the larger systems do? Are you seeing those gaps? And what is the interaction and the communication like between your laboratory, administration, management, technologist, and then pathology and pathologists? Don't forget to unmute yourselves if you'd like to speak. Or you can put your question in the chat.

Heather Duncan: Don't be shy. And I'll say, from our perspective, we are very rural here. And it can be difficult just to attract pathologists. I think that in general is very– can be very difficult.

Triona Henderson: Right. That also is a challenge, I think, recruiting pathologists and even technologists if you're really in the rural areas of certain states.

Heather Duncan: There's a lot of competition.

Nathan Tuka: So this is Dr. Tuka in Pathologist Diagnostic Laboratory. I will say, I've had– and speaking for all hospitals in low resource, one of my first laboratory directorships was with a lab that was undergoing bankruptcy, or the hospital was undergoing bankruptcy. To the point about training, in training that's not something you get training about, I don't think, at least in my training, which I thought was very good overall. But it's a challenge when you're trying to figure out, you can't afford a PT, and trying to communicate with hospital administration, and take care of patients. I don't think it's something that's generally addressed. But with on the news, hearing about the impact of the finances of rural hospitals, I think it's probably a problem that's going to be increasing in prevalence. So let the group comment on that.

Triona Henderson: And I would love to pose to you, Nathan, because a question came in the chat, which is another layer to this. So they're saying that, our pathologist is 50 miles away. And we only see them quarterly. So we depend on the lab staff mostly.

So even with delegated tasks, if you're seeing your pathologist once every three months, how are you handling even your quality management system? How are you getting that daily interaction and that interaction with the other sub-specialists outside of the laboratory?

Nathan Tuka: So, I guess, in my experience, and it's something the other rural hospitals would have, we try to have regularly scheduled meetings depending on what the administration is needing and trying to grow those relationships. But you do depend a lot on your staff to handle issues on a day to day basis. And I think there's an element of trust. So that needs to be there in terms of you trusting them, but also you trusting their ability to know when they need to bring you in. And I think that's important for them to know when they've reached their limits and when they need medical director input.

Heather Duncan: I can [INAUDIBLE] my previous experience and because– to this one, we had an off-site director. She probably came once per year physically. You have to demonstrate your lab director's involvement in your activities with your quality plans. When I speak about electronic signatures and using electronic technologies, we really utilize that quite heavily to demonstrate involvement.

So she provided consultation, and we had a quality meeting and provided minutes and feedback with proficiency testing. And we did a lot with electronic communication to demonstrate that interaction a lot by phone, quite a bit by phone. But physical interaction, we– just because of distance.

Triona Henderson: So there's a comment from Lauren Tyson. Resources in regards to contracting. We utilize our health care system to establish contracts that include all sites of care. There is strength in numbers. This ties in the smaller labs allowing them to have the resources of the larger labs. And it may also be one of the reasons why, especially on the East Coast, we're seeing a lot of consolidation of laboratories.

And I know, Heather, you're a hospital system. So you said you're the flagship of nine hospitals. And so are the other hospitals even more rural than your hospital?

Heather Duncan: Very much so. Very much so. We have hospitals that are two plus hours away, very, very rural. We have a hospital that's in the Outer Banks, which is– we deal with weather. We deal with, especially– we've had flooding. We've had numerous events with flooding where we've had to have helicopter rescues for– and deliveries of supplies. So most of our hospitals are extremely rural.

Triona Henderson: Any other comments about how other hospitals systems have tried to bring together your outlying labs and/or hospitals? Sorry. Can you advance the slide?

Heather Duncan: Oh yes. Sorry. Yes.

Triona Henderson: Perfect. So we are excited to have our next session for March. It's going to be on Wednesday, March 18th at 1:00 PM. The topic is going to be a Laboratory 2.0: Lab Leadership's Link to Patient Outcomes. And this will be presented by Dr. James Crawford from Northwell Health in Lake Success, New York. Sorry. So please visit the DLF ECHO website to registered for this session and to view all future sessions.

Thank you for taking part in our discussion today. We hope you find it valuable in the important work that you engage with in your individual laboratories. We look forward to your participation in future sessions as we dive into specific laboratory subspecialty topics.

So after Heather's presentation– so her presentation was the community laboratory perspective. And then for the rest of the year, we're going to have the larger academic institutions present their work and their cases. Now we will adjourn. Thank you, and have a great day.

Additional resources and related publications

Challenges in Community Laboratories

• Scheifele LZ, Burkett T. The First Three Years of a Community Lab: Lessons Learned and Ways Forward. Journal of microbiology & biology education. 2016;17(1):81-5.
• Fell L. Opportunities in Rural Laboratory Medicine. Laboratory Medicine. 1998;29(11):665-667

Laboratory Competency Assessment

• Sharp SE, Elder BL. Competency assessment in the clinical microbiology laboratorypdf icon. Clinical microbiology reviews. 2004;17(3):681-94, table of content.
• Desjardins M, Fleming CA. Competency assessment of microbiology medical laboratory technologists in Ontario, Canada. Journal of clinical microbiology. 2014;52(8):2940-5.

Laboratory Quality and Management

• Meier FA, Badrick TC, Sikaris KA. What's to Be Done About Laboratory Quality? Process Indicators, Laboratory Stewardship, the Outcomes Problem, Risk Assessment, and Economic Value: Responding to Contemporary Global Challenges. American journal of clinical pathology. 2018;149(3):186-196.
• Koethe S. Hospital Laboratory Leadership and the Dyad Model of Management. Laboratory Medicine. 2013;44(2):168-171.
• Verna R, Velazquez AB, Laposata M. Reducing Diagnostic Errors Worldwide Through Diagnostic Management Teams. Annals of laboratory medicine. 2019;39(2):121-124.
• Singh H, Naik AD, Rao R, Petersen LA. Reducing diagnostic errors through effective communication: harnessing the power of information technology. Journal of general internal medicine. 2008;23(4):489-94.

Point of Care Testing

• Wiencek J, Nichols J. Issues in the practical implementation of POCT: overcoming challenges. Expert review of molecular diagnostics. 2016;16(4):415-22.