Director of Pathology & Lab. Medicine Responsibilities
When our 100 bed hospital opened in late 1971,
Dr. Calvert was a solo pathologist filling this role alone. In the
late 1970s, our hospital desired to gain administrative control
of the lab. During two years of contract negotiations in early
1980s, the pathology group was made to be "resource medical
directors" (rather than "in charge", leadership
medical directors). In about 1980, Dr. Carter accepted the position
of being the new Medical Director of a downtown Chicago Hospital
which had failed Joint Commission inspection of its administratively
run lab for the second time and was under threat of sanction. Dr.
Carter resurrected that lab as a real pathologist leadership medical
director. He joined the group here in Lexington in 1984 and was
instrumental in converting the directorship back to a true pathologist
leadership medical directorship. There have been at least two serious
non-pathologist attempts to alter this directorship situation.
But, we remain a fully leadership medically directed lab now (4/2005)
serving the busiest ER in South Carolina, one of the highest-volume
birthing centers in South Carolina, a 110-doctor MSO, and over
300 acute-care general hospital beds.
Here is one example of a single simple but important
director's memo with decisive leadership
direction on a single computer issue . Since 1971, there
have been multiplied hundreds of such directorate memoranda; and
there have been vast numbers of less formal medical-directing verbal & written
communications within our group & lab in order to maximize
efficiency toward the optimization of patient diagnosis & care
tailored to our unique set of circumstances. Communications flow
there-from to other components of the Lexington catchment area,
the Lexington County Health Services District (LCHSD), and to physicians
[example] and their offices.
DHEC, CLIA, JAHCO, CAP, AABB and other accreditation
organizations have extensive (wide & deep) requirements for
directorship responsibilities. Medical directorship is facilitated
by having additional pathologists secondarily responsible for each
area/subdivision of the lab. Our group is very extensively involved
in all areas, the involvement falling under the following example
headings (not a complete list):
- Assuring provision of pathologist consultations about the medical
significance of clinical laboratory test information.
- Assure proper performance of all anatomic pathology procedures.
- Assure responsiveness to appropriate persons with questions regarding
quality assurance and significance of test information.
- Assure that all pathologists serve as active members of the medical staff,
with reasonable and appropriate involvement in inter-departmental and
- Assure that the pathologists and the laboratory operation relate and
function effectively with accrediting and regulatory agencies, administrative
officials, the medical community, the medical device supplies and services
industry, and the patient population served.
- Define, implement, and monitor standards of performance in quality
control, quality improvement and cost effectiveness of the pathology and
clinical laboratory services.
- Assure monitoring of all work performed in the laboratory in order to
determine that medically reliable data are being generated (to include a
reasonable SOP for delta checks and alert values), to assure
effective and timely response to concerns about such from those who utilize
the department of pathology and laboratory medicine.
- Assume responsibility for implementation of the laboratory's Quality
Improvement Plan. The Director (or designee) and professional laboratory
personnel participate as members of the various quality improvement committees
of the hospital.
- Insure that there are sufficient qualified personnel with adequately
documented training and experience to meet the needs of the laboratory's
service to medical staff and patients.
- Assure that a system is in place to provide annual competency testing for
all who conduct laboratory testing.
- Strategic planning: Develop plans, set goals, and develop and allocate
resources appropriate to institutional goals, medical staff needs, and patient
- Administrative and management responsibilities: assure provision of
effective administration of the Department of Pathology and Laboratory
Medicine, including budget planning and control, with responsible financial
management appropriate to the breadth, depth, and intensity of laboratory
- Educational responsibilities: assure the availability of appropriate
educational programs for the medical and the laboratory staff and assure
reasonable participation in educational programs of the hospital.
- Implement and direct research and development of laboratory services, as
- Select and monitor all reference laboratories for appropriateness and
quality of service, with a FYI-type of MEC approval.
- Assure a safe laboratory environment in compliance with good practice and
|(posted 3 March 2005; latest addition 9 May 2005)
1999 - 2006, all rights reserved, Pathology Associates Of Lexington,