Sunday, September 23, 2012

Laboratory Physicians and Competency Assessment

On two occasions in the recent past I have been asked about how we would establish a system of competency testing for pathologists and clinical laboratory physicians.  I see just asking the question as a positive and maturing step forward along the Quality pathway.  By and large laboratory docs lead a charmed and protected life, being immune to requirements, except in the first 6 months of probationary hiring, and as we will experience more and more in the upcoming years, at the end of their career.  It is an anomaly, since near every one else in the laboratory is expected to demonstrate competency, and further, in the corporate arena, even the CEO is held accountable.  Perform and survive.  And even ISO 15189 makes it clear that everyone should be assessed for competency on a regular basis.  

So it is not a question of whether, it is a question of how.

But to be clear, I am a strong supporter of Samuel Culbert who wrote “Get Rid of the Performance Review”.  However named, and regardless of how many degrees (360?) are involved, Performance Reviews rarely, if ever, create an objective and accurate and productive product.  Pretty much a waste of time.

It seems to me that the natural place to start is with the job description.  Most laboratory physicians are hired to perform certain functions, and it follows that performance on each of those functions can be monitored and performance can be objectively assessed.  

My list of tasks includes:
1. To perform certain tests and functions that require special training.
a. Function as a discipline leader
b. To perform knowledge specific skills.
c. To provide interpretive skills for highly specific laboratory test results.
d. To provide  interpretive insights on all test results as required.
e. Function as a discipline educator

2. To perform certain supplemental skills including 
a. To be aware and up-to-date on new advancements within their discipline.
b. To provide innovative change within their specific discipline.
c. To meet customer satisfaction
d. To be a contributor to Quality improvement 

If that is an acceptable task list, we can start with the ones that should be easy  to monitor.  

The physicians are either reading and interpreting slides or they are not (1c,d,e).  Similarly, the microbiologists are making bench rounds or they are not.  Or they are involved in infection control.   The chemists and geneticists are either looking at specific electrophoretic patterns or they are not.  If they are taking responsibility for these high skill tests, they get a score of (PLUS1); if not, then they get a score of Zero.  For almost all these tests, there is usually proficiency testing challenges available to supplement the score.  For those tests where PT does not exist, then there should be an expectation for them to develop and alternative.  

On a similar note, laboratory physicians either put on formal education sessions or they do not (1e).  Maybe not every day or every week, or even every month, but there should be an expectation that laboratory leaders share their knowledge on some sort of a regular basis, either alone or through invited presentations with others.  

Keeping up to date (2a) is a common measure in many assessment schemes.  Docs have to participate in CME in some form regularly and all the time.  It may be passively by attending meetings or viewing on-line information, or actively by being a meeting or on-line information sharer, or a manuscript writer, but there must be evidence that the person is thinking about their professionally duties, and keeping up or in some instances ahead of their peers.  [Note to self: I wonder if writing this blog would count?]  Again, marks given for performance.

Being a part of Quality (2c,d) can be similarly examined:  Is there evidence that complaints are being followed up, or worse, that they are not?  Is there evidence of supporting, endorsing, and participating in internal audits in their discipline?  Is there evidence that they have worked actively in the preparation for accreditation?  Get marks for each.

That leaves two more difficult issues, being a leader (1a) and an innovator (2b).  In some regards these can be linked at the point of “change” and “change management”.  If a laboratory is doing everything the same today as it did 10 years ago, there is something wrong at the top.  No new tests? No new work flow? Not new reporting structure?  No new learning initiatives?  Count all that as evidence of No Leadership.  Leadership and Innovation are not the same as buying new equipment and spending tons of money.  Both are about being creative.  Given time, I would expand the options here,  but “change” is a pretty good place to start.

Want to make things more demanding; consider weighting leadership and innovation and Quality as twice as important as performance of specialized tests.  Create a composite score and monitor on a year-over-year basis, and set certain expectation levels.  

I am interested in thoughts and comments, and perhaps alternative approaches.


  1. Most of the tasks you list are actually in the current accreditation standards for medical laboratories in British Columbia. Some are mandatory items, some are not. And rightly or wrongly, I'm not sure that accreditation should be too focused on innovation.

    Although accreditation is done on a facility by facility basis, it is interesting to think about looking at individual physicians. One area (among others) that accreditation will force facilities to look at individual physicians is medical peer review.

    With regard to 1c and 1d, there are now accreditation requirments for laboratory medicine facilities to have a peer-review program in place. I understand that working out what the actual process for peer-review will look like is much easier for some disciplines than others. But peer review for laboratory physicians is coming to a laboratory near you.

  2. I'm not sure about total abolition of performance reviews for medical professionals though. We still need an accepted standard to base our practitioners' capabilities on. But you're right, pathologists and clinical lab physicians need to have a QA check on the regular too.


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