Within this department, there are three areas for attention: the laboratory activities of the technologists, the diagnostic activities of the pathologists staff, and the ordering patterns and laboratory utilization of the clinical physicians.  Within the department, monitoring programs have existed for the technologists and pathologists.  There have been on-going , much-less-formalized means taken to influence the activities of clinical physicians, or to set up alternate methods by which opportunities can be seized to improve patient care.  While these activities have been copious, it is estimated that less than 10% have been documented.  "New-format" types of documentation will be approached, and we will happily cooperate with monitoring functions as determined by the clinical departments. 

Though the pathologists might learn of opportunities to improve patient care, the impact on the medical staff may be a basis for controversial reaction or resistance.  Numerous diplomatic devices are employed to achieve change.  At the request of this department, the medical staff created a Laboratory Liaison Committee.  Selected topics are presented to that committee in order to explain the opportunity sought in a given change, and to receive advice as to whether this will meet the needs of the medical staff, and to receive advice as to implementation. 

Informal contacts are a terrific source for formulating a consensus as to the quality and appropriateness of services of services both from within the department and requested of the department.  These are offered up from the technologists by way of their friendships, discussions, and readings.  The pathologists learn of significant information through their meetings, nationwide contacts, professional friendships, and professional readings.  Discussions between the pathologists and the medical staff allow an informal assessment as to both the quality and appropriateness of ordering patterns, as well as opportunities to improve care. 

The department has an extensively documented and monitored program of quality control of the work of the technologists.  A number of the tests (for example, the protocol review of CBC abnormalities) require a pathologist follow-up review, and possible interpretation.  The pathologists exercise an intradepartmental QC program of their case diagnoses; numerous intradepartmental consultations are made; and these help to refine the reproducibility of diagnosis among the several pathologists.  Liberal usage is made of extra departmental consultations, allowing diagnostic capabilities to be compared on a national scale.  Information is carried from the department, monthly, to the Medical Executive Committee.  At less frequent intervals, pathologists attend the clinical departmental meetings to present and receive information.  The Vice President for Professional Services (or his representative) attends the clinical departmental meetings and advises the pathologists of discussions which might indicate complaints or opportunities to improve patient care.  The Quality Assurance activities of our department involve all of the above groups in discussions and decisions regarding appropriateness. 

It is highly recognized within the specialty of pathology that "curb-side" discussions of cases with clinical physicians is the most successful method of influencing quality and appropriateness in specific cases (both the pathologists influencing the clinician, and vice versa).  When these type discussions are used with frequency and determination, and imperceptible but decisive impact is made on the medical staff for the general betterment of patient care.  This has always been a prime strategy within this department. 

Widely recognized within our specialty is the tremendous impact on appropriateness of laboratory test ordering patterns which is made by changes in laboratory requisition forms.  When these forms are constructed with the best interest of the patient and the clinician in mind, great changes can be made with little or no controversy.  This is done by proper and logical clustering of laboratory tests on logical forms.  Most of our forms allow a space for interpretative commentary.  For some tests, the greatest opportunities for improvement of patient care are seized when the pathologists regularly interpret the test results and indicate the next logical test in the workup sequence.  Upon computerization of a laboratory, it is important to have mechanisms within the request program which allow the accomplishment of this same type of influence.  In order to properly devise the test strategies, the pathologists rely on long experience, appropriate reports in medical journals, and (most importantly) recommendations from experts throughout the United States. 

Lastly, the ability of the clinical physicians to feedback "problems" with the laboratory is of great importance.  This can be in the form of comments, suggestions, or gripes, as previously noted above.  And these can impact on the betterment of care both in individual and general cases.  It is essential that the clinical physicians notify the laboratory of test results which make no sense.  This is often the only way to detect irregularly recurring problems with instruments or personnel within the laboratory.  In order for the clinical physicians to properly accomplish this, they must feel that their pathologist colleagues are "with them" and not "against them".  This lab has long maintained a very positive relationship with nursing and the medical staff.  It seems that all feel freely able to deliver constructive criticism.  In order to take advantage of a physician's possible feedback at any hour of the day, 365 days out of the year, the lab installed a telephone answering device for the receipt of such information. All clinical hospital telephones are supposed to have this number posted on them.