Medical Director Responsibilities in Clinical Pathology
During my career I have often been asked to describe the role of the medical director of the clinical laboratory. CLIA Amendments list specific requirements of the laboratory director, but I have never felt that they clearly explain what I do on a daily basis. Therefore, I have compiled the following list. Please let me know if I have omitted some pertinent functions.
Laboratory Operations
- Make daily rounds throughout the laboratory
- Be familiar with all disciplines within the clinical laboratory
- Serve as a liaison between the medical staff & clinical laboratory scientists
- Be accessible to the laboratory staff to provide onsite, telephone or electronic consultation as needed on a 24 x 7 basis.
- Instruct laboratory staff to refer all abusive physicians to you
- Develop and maintain an effective working relationship with laboratory management. Attend their meetings and actively participate. Assist them in setting goals, objectives, policies and procedures. Advise in the acquisition of capital equipment.
- Ensure the laboratory has sufficient qualified personnel with adequate documented training to meet workload demands
- Build a strong team, delegate authority and hold people accountable
- Ensure that managers and supervisors have sufficient experience and expertise to lead their sections of the clinical laboratory
- Interview candidates for management and supervisory positions in the laboratory
- Promote a safe laboratory environment for personnel and other occupants
- Assist in growing pathology and laboratory business by developing new and maintaining existing clients
- Review all new laboratory procedures and participate in the biennial review of procedures
- Establish a method evaluation protocol and review data prior to implementation of new methods and analyzers
Quality
- Ensure that the laboratory monitors and evaluates the quality and appropriateness of services rendered within the context of the quality assurance program of the institution.
- Assure quality of laboratory results by reviewing quality control, proficiency surveys & patient data. Attend Performance Improvement committee meetings.
- Review the quality assurance/quality management report on a regular basis
- Ensure that the laboratory is enrolled in proficiency surveys for all analytes, thoroughly investigate discrepant results and document corrective action
- Review all incorrect proficiency test results and implement corrective actions.
- Periodically review patient results to determine that medically reliable data is being generated.
- Promptly investigate laboratory errors and develop an action plan to prevent future occurrences
Regulatory
- Ensure that pathology and laboratory comply with all current accreditation and regulatory agencies such as AABB, CAP, CLIA, FDA, JCAHO, and state.
- Ensure that the laboratory maintains a constant state of inspection readiness and is prepared for unannounced inspections by accrediting agencies
Utilization
- Promote appropriate test utilization by physicians, residents and other providers
- Ensure the cost-effectiveness of the clinical laboratory by discontinuing obsolete tests, evaluating requests for new tests and reviewing orders for esoteric tests.
- Decrease unnecessary transfusions by participating the Blood Management Program reports
- Determine which tests should be performed in-house and which ones should be sent out.
- Review send-out tests on a semi-annual basis to determine if tests should be in-sourced
- Assist in selection of all reference laboratories and monitor their performance and cost
- Evaluate all requests for point of care tests and ensure they are medically necessary
- Compare performance of point of care tests with tests performed in the laboratory
Medical Staff
- Maintain constant open-ended communication
- Serve as an active member of the medical staff and participate in medical staff committees.
- Gain the medical staff's respect and support for new laboratory initiatives.
- Provide consultation to referring physicians in a timely manner regarding:
- Inclusion of appropriate tests in clinical order sets and deletion of unnecessary tests
- Interpretation of esoteric laboratory test results
- Investigation of discrepant or unexpected results
- Determination of which tests should be included in critical value lists
- Educate the medical staff, house staff, medical students and nurses about significant changes in laboratory operations
- Oversee charting of laboratory test results in the laboratory information system and electronic medical record to facilitate appropriate test ordering and results interpretation
- Determine if lab test turnaround times are meeting the needs of the medical staff.
Health System Administration
- Demonstrate to hospital administration how your laboratory provides added value for hospital operations, patient care and patient safety
- Communicate laboratory’s strategic plan including projections for people, space and capital equipment
- Obtain adequate resources for the laboratory
Education and Research
- Be a lifelong learner and stay abreast of new developments in laboratory medicine
- Provide educational direction for the medical laboratory staff and participate in educational programs of the institution as appropriate
- Support medical laboratory scientist training programs and promote your laboratory as an optimal place of employment
- Oversee the laboratory's participation in clinical research studies
