April 2010

Stephen N Bauer , MD, FCAP

A yardstick for transformation

Jim Collins researches companies and organizations to figure out what distinguishes the very best from very good. He studies a handful of highly successful groups that have been through tough times and emerged the better for it, then mines the data for trends and drivers. He has reported the results of his research on not-for-profits in a monograph, Good to Great and the Social Sectors (and a longer parent book, Good to Great, which focuses on the same principles in the for-profit world).

Outstanding organizations, Collins says, are characterized by highly motivated people who are genuinely passionate about their work and know exactly what it is they do better than anyone else. The College would be one of his hybrid groups, a not-for-profit with business-related income, like the Mayo Clinic or Goodwill Industries. For them, as for us, a well-deserved reputation for quality and integrity generates loyalty, which in turn motivates members to contribute time and talent.

An organization succeeds in large part, he says, because it has the right people, people with a passion for what they do, people with an almost unreasonable focus on excellence, people who don’t know how to give anything but their best because that’s just how they’re wired.

Forty percent of our 11,000 practicing fellows contribute at least 180,000 hours per year in service to the specialty. If the No. 1 requirement on Collins’ list is to have the right people, we can check that one off.

We also have the passion and the knowledge that there is one thing we do better than anyone else: design, maintain, and grow quality drivers in the practice of pathology.

One of the first activities of the newly formed CAP was proficiency testing for clinical laboratories. We mailed the first Surveys in 1949 and have been immersed in quality improvement ever since. From laboratory accreditation to cancer protocols, excellence is central to our mission. Pathologists are famously inclined to raise the bar, not slide beneath it. We love our data. As the tailor says, “Measure twice, cut once.” We like to get it right; it’s how we’re wired.

Some things are measured more easily than others. The business side of the College can be tracked via financials and client satisfaction. The professional side is another matter. What metrics can we use to track how well we meet our members’ needs and expectations? Specifically, how successfully are we encouraging support for transformational pathology at the grassroots?

I learned on committees of the College much of what I understand about measuring intangibles. During the 1990s, I was asked to represent the College on the American Medical Association Current Procedural Terminology and Resource-Based Relative Value Scale (RBRVS) Update committees, which developed tools important for pathologist and laboratory payment. Then, when the federal government’s Health Care Financing Administration was looking at limiting access to laboratory tests, physician groups successfully lobbied Congress to require that the agency employ negotiated rulemaking to find consensus among the stakeholders, and I was asked to represent the College on the HCFA Negotiated Rulemaking Committee for Laboratory Testing.

That turned into more than a year of trips to Washington every six weeks to work with government officials, other physicians, and representatives of the laboratory industry to negotiate federal payment policies. We spent a great many hours with the International Classification of Diseases code book, identifying diagnosis codes associated with specific laboratory tests. There was a good deal of tedium punctuated by occasional (“if you do that we’ll walk right out”) posturing, but we were thorough and thoughtful and stubborn when we needed to be. Nobody was completely happy with the results, but I think everyone felt the process was fair.

I learned from these experiences that setting meaningful measures for nebulous notions like quality, effort, and usefulness is not easy, but it can and must be done. It’s essentially about identifying benchmarks and being rigorous in assigning value to them.

When the transformation story is finally written, it will be the story of countless individuals who led the way. The College must provide resources for them to create that story. For now, we need to know whether we are consistently engaging our members in the work of transformation. Are we doing all we can to provide opportunities for lifelong learning and create a culture that supports intellectual curiosity? How well have we inculcated a level of comfort with the modern consultative model? How many of our members are pursuing continuing education in new technologies? How many are members and chairs of hospital committees? How many devote at least some of each week to direct patient care activity? In short, has our membership fully embraced transformational pathology? Are we doing all we can to fuel their evolution?

The CAP leadership has been grappling with these questions, searching for ways to ensure we are providing what our members need. We don’t know what pathology will look like five years from now, but we do know our members and dedicated staff have the means, strength, and brains to shape it. Please write to me with any suggestions you might have as to what more we can do, and what metrics we might devise to track the quality of our efforts to fuel the engine of transformation.

It’s almost like when you were a kid going to Grandma’s house. You would ask your mom, every 10 minutes, how much longer it would be, because you were little and didn’t know the landmarks. We don’t know, right now, where Grandma’s house will be, but we do know we are responsible for finding the landmarks. And we are determined it will be our job to build it.