Departments of Pathology & Translational Molecular Pathology Productivity and Efficiency of an Anatomic Pathologist-Challenges & Opportunities Dipen Maru, MD Professor Departments of Pathology & Translational Molecular Pathology

Productivity-Definition Labor productivity: Measure of economic performance that compares the amount of goods and services produced (output) with the number of hours worked to produce (input) Multifactor productivity: Measure of economic performance that compares the amount of goods and services produced (output) to the amount of combined inputs used to produce those goods and services* *United States Department of Labor *Unites States Department of Labor

Productivity-Definition Pathology administrative leaders need to differentiate between labor vs. multifactor productivity when establishing benchmarks for productivity and incentive programs for faculty and classified staff

Productivity in Anatomic Pathology-Inherent Challenges Aligning productivity measures with wRVU Few data points available to collect healthcare outcome information for pathologists Limited scope of expansion or modifications of clinical practice Measures applicable to clinicians are difficult to apply for pathologists

Existing Models wRVU Days of service, number of cases, number of slides, TAT or combination of all or some of these Automatable Activity Based Approach to Complexity Unit Scoring (AABACUS) Royal College of Pathologists Guidelines on Staffing and Workload Calculated weighted value based on complexity (L4E)

RVU Relative value of work for a subspecialty based on certain factors* Work required by a physician: a. Time b. Mental effort and diagnostic acumen c. Physical effort or technical skills d. Psychological stress by magnitude estimation Cost of maintaining practice Liability expenses ?? Cost of acquiring skills/education 1 to 3 x geographical adjustment x conversion factor=RVU in $$ *Hsiao et al. NEJM, 1988

How does RVU relates to effort and time spent on providing clinical service

Associations of Pathology Chairs Survey* Annonymized data from 629 pathologists from 51 pathology departments Median cFTE: 0.7 (range 0.05-1), Median Days on service 148 (5-365), median (range) wRVU 4644 (4-14160) Four practice models a. General, b. Hybrid, c. single subspecialty, d. Multiple subspecialties Compare data with MGMA and FPSC benchmarks *Ducatman B. Academy Pathology, August 2016

APC survey General (n=170) Hybrid (n=193) Single Subspecialty (n=176) Multiple subspecialties (n=90) p Part A effort (FTE)>0 0.11 0.19 0.15 NS Part B effort (cFTE) 0.7 0.55 0.67 <0.003 Days on service 130 152 150 171 <0.02 wRVU 5215 4479 2662 5426 <0.001 Education effort>0 0.12 0.1 Research effort>0 0.05 <0.004 Median Salary $221216 $234171 $241500 $235000

Effort vs. wRVUs (APC survey)

Days on service vs. RVU

AABACUS* Automatable Activity-Based Approach to Complexity Unit Scoring *Cheung C. Modern Pathology, 2015 (28)

AABACUS Automatable Activity-Based Approach to Complexity Unit Scoring Calculation of Pathologic Clinical Units in AABACUS Clinical workload unit by AABACUS Information in LIS

AABACUS Capture from LIS: “Raw Parameters” generating by the Department using LIS Export: As excel files to AABACUS Identify: Workload Parameter: # blocks/slides/stains Workload Activity: Specimen acquisition, Handling, Analysis, reporting and QA activities

AABACUS Count: Number of activities by the Pathologist Score: Number of activities x complexity factors

UTMDACC Survey Surgical Pathologists with committed clinical effort 60-70% Subspecialties where we got responses from more than 1 pathologist Effort of activity as % of clinical commitment

Effort required for clinical activity Mean (%) Range SD Frozen section diagnosis 10 1-16 5 Gross examination 13 10-21 H&E review with and without review of non-pathology modalities 41 35-55 2 Dictation/sign out 11 5-18 8 Ancillary studies 9 3-20 7 Biomarker related work 3 1-5 Consultant 6 2-12 Tumor board or planning clinic 4 0-10 Committee meetings related to direct patient care 1

Non RVU Generating Activities Mean Range Standard Deviation Grossing Supervision 6 1.7 Specimen harvest for clinical research 2 1 Tumor Board/Planning clinic 4 0-10 3 Consultation with clinicians and other pathologists 2-12 Department and institutional committee meetings 5 1-7 1.5 Development and establishing a new test, protocol, overseeing daily operations * NA

UTMDACC survey 23% of clinical effort to activities without wRVU Activities related to QA/QC Better documentation is necessary for activities which targeted to improve quality of clinical care for billing purposes Need for efficiency: Not only for financial incentive

Processes Needing Efficiency Improvement Service Schedule Number of services in your section Distribution of service days across week or month Mix of activities in one service Specimen/Slides related issues Grossing delays Grossing mistakes Processing and staining delays (for HE only) Ancillary testing delays Ancillary testing mistakes Unpredictable work flow of ancillary and biomarker testing Transcription issues IT issues

Processes Needing Efficiency Improvement Tumor Board/Planning clinic Number of meetings Time take to prepare Issue related to availability of material for review and present Number and types of cases in each meeting Activities other than those not related to providing direct pathology services for patient care Coordination of workflow with fellows Meetings and non academic commitments

Measures not directly related to Billable units TAT Number of Amendments Communications related to Patients Utilization of best practices Department/Subspecialty Specific QA/QC activities Grossing supervision Specimen Harvest for research Tumor board Committee meetings Clinical Measures not directly related to Billable units Number of days on service Number of cases/Slides wRVU Establishing a test for the department Quality Matrix 2 3 or 4 1 3 or 4 Measures directly related to billable units

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