Lead Like No One is Watching

Even though I readily share and celebrate my accolades with family and friends, I have generally been quiet with my coworkers regarding career moves. When I passed the ASCP Specialist in Cytotechnology BOC exam three years into my career as a cytotechnologist, I only shared the news with my supervisor, cytopathology director, and a few other pathologists. After dabbling in budget and supply purchasing and compiling monthly and annual QA statistics, I completed ASCP’s certificate program from Lab Management University in 2018. The following year, I traveled to Puerto Rico for the American Society for Cytotechnology (ASCT) conference and sat for the International Academy of Cytology (IAC) Comprehensive Examination. Six weeks after the exam, I received word that I passed, and again, I immediately shared the exciting news with my supervisor and cytopathology director. No one else at work had a clue until a year later when they noticed extra initials behind my sign-out signature. Then, the ASCP 40 Under Forty application and eight weeks of waiting came and went this past summer and once again, I elatedly celebrated with my superiors. I have always moved in silence amongst my peers to maintain an inclusive and docile/same-level environment. While some might be supportive, not everyone actively encourages growth. Furthermore, not everyone wants an all-you-can-eat buffet on their work plate, and many lab professionals are happy with a less stressful, entry-level competency kind of routine. And that is perfectly A-OK too! Regardless, I am who I am, and for the lab professional who loves continuing education and learning new techniques and advancements across the field of health care, I wondered what career moves I would make in 2021. What goals should I set out to achieve? What is my next step?

There it is. A doctoral program. 100% Online and meant for the full-time working professional. I have officially embarked on my eight-semester-long journey to earning a Doctorate of Health Science (DHSc) with a concentration of Organizational Excellence in Healthcare. Rather than a traditional PhD which prepares scholars for research-based careers in a very focused area, the DHSc is an applied doctorate focusing on healthcare leadership in various disciplines. Now that I am halfway through my first semester, I can honestly say this is one of the best decisions I have ever made. Learning about applied leadership theory in healthcare and how to effectively, efficiently, and efficaciously lead in a complex healthcare landscape has been so intellectually stimulating thus far. Most recently, my classmates and I engaged in a discussion emphasizing how today’s leaders must stay relevant in their dynamic fields, and we shared our required competencies (i.e., the knowledge, skills, and abilities) for leading people and managing resources for both today and tomorrow (Ledlow & Stephens, 2018). A recurrent theme we uncovered is the necessity for continuing education – whether it be formal or informal. Staying relevant requires healthcare leaders to read, research, and teach. As cytotechnologists, we have existing continuing education programs in place, such as ASCP’s Credential Maintenance Program, recommending certificants to participate in and record credits to renew their certifications. We have Interlaboratory Comparison Programs through the College of American Pathologists (CAP) that feature ancillary studies as a diagnostic companion to cytology slides. We watch cytoteleconferences provided by the American Society of Cytopathology (ASC). We are encouraged to attend our affiliated societies’ national conferences to collaborate interprofessionally. With all that is available, however, we still need to do more than just claim continuing education credits.

We need to stay abreast on how our field of laboratory medicine is changing and how we can accommodate those changes and adapt to those changes. We need inspiration and motivation throughout the organizational hierarchy. We need passion and commitment from all levels and all disciplines. We need transformational, flexible, and culturally competent leaders to serve as mentors for the next generation of leaders. We need leaders who continuously self-reflect and improve as they build diverse, yet cohesive teams that thrive on generating positive outcomes for the organization. To the current leaders, leaders-in-training, and the followers with potential – we must get better, we must take more initiative, we must aspire to learn more than just the “what” or the “how,” but most importantly the “why.” For the upcoming year and beyond, I challenge you to continuously learn more about your field of laboratory medicine and its impact on society. Ask why the pap guidelines have changed. Ask about the advantages of robotic bronchoscopy. Ask what molecular tests are available and which are currently in development. Ask what we can do to reduce the burden of disease in our community! Refrain from saying, “I don’t know” and respond with, “I’ll find out.” Become an expert in your field by understanding the interdependency of laboratory disciplines and beyond, and strive to actively network with each other. For those who want more, please do more! Pursue more! There is no ceiling on your potential, and there are no limits to your growth.

So sayonara to 2020, and hello to 2021! New year, new me? No. New year, improved me. And hopefully an improved you!

Image 1. “Be a Star!” (Thyroid, FNA – DQ-stained smear. Dx: Papillary Thyroid Carcinoma)

References

1. Ledlow, G.R. & Stephens, J.H. (2018). Leadership for health professionals: Theory, skills, and applications (3rd ed.) Jones & Bartlett Learning.

-Taryn Waraksa, MS, SCT(ASCP)CM, CT(IAC), has worked as a cytotechnologist at Fox Chase Cancer Center, in Philadelphia, Pennsylvania, since earning her master’s degree from Thomas Jefferson University in 2014. She is an ASCP board-certified Specialist in Cytotechnology with an additional certification by the International Academy of Cytology (IAC). She is also a 2020 ASCP 40 Under Forty Honoree.

2020: Lessons Learned in Lab Safety

2020 will be a year for many to remember, no matter your profession. If you worked in a laboratory, though, you know many things happened along the way which were both difficult and unexpected, and much of the year was consumed with work surrounding the COVID-19 pandemic. Changes and challenges came along which would test the resiliency of any lab safety professional. With luck, though, there were good lessons learned and new ideas about how to face certain lab safety issues in the future.

The Fear of Biohazards

One of the earliest challenges many lab leaders faced this year was dealing with the fears of staff who would have to work with COVID-19 patients and specimens. With the news reporting daily death tolls and unscientific data (like mortality rates when the total number of cases could not be determined), the amount of fear that was generated for some people became obvious at work. Staff members became afraid of handling any specimens, and people began unnecessary practices like double-bagging swabs or wearing gloves when transporting specimens.

Getting employees to deal with those fears and to continue to work became a priority for many very quickly. Many lab leaders conducted meetings and educational sessions. It was important to remind staff that they usually handled specimens every day which contain bacteria and other viruses that could be as harmful to them. They had to remember that if they used Standard Precautions with all samples, they could remain safe. In some locations COVID-19 FAQ newsletters were used to address hot-button issues and answer common questions about PPE, high-touch surfaces, and aerosol generating procedures. It was a good lesson to learn, lab staff need regular information about the proper handling of the hazards they work with and knowledge about how to remain safe on the job.

PPE Changes

Another challenge that arose was trying to keep up with the changes in recommendations for PPE use in the lab and for those who collected COVID-19 swab specimens. In the beginning of the year, masks were not required in the workplace, but that changed. Then cloth masks were not allowed in some organizations. The use of face shields or goggles was mandated, in some locations they were even required in break rooms and hallways. Phlebotomists who once wore only gloves now had to wear gowns, masks and face shields, and in some instances N95 respirators were used. These changes required education, training and an explanation for staff as to why the extra PPE was necessary.

Changes also came to how laboratorians would utilize PPE. Because of international shortages of supplies, the CDC provided information about extended use and re-use of the equipment. Organizations moved from using disposable lab coats and gowns to reusable ones. Hospitals had to set up methods for reprocessing and disinfecting gowns and N95 respirators for reuse using UV lighting or a hydrogen peroxide vapor treatment. Laboratorians and other healthcare workers learned how to extend the normal wear time of N95 respirators, masks, and other disposable PPE and how to store items rather than toss them out. While PPE supply issues seem to have calmed down, labs learned many lessons about how to handle such shortages in the future.

New Testing

As the pandemic progressed, many labs were asked to bring on board new COVID-19 testing. This testing typically had to be brought on board quickly, and in some cases new laboratory space had to be found. Many considerations had to be discussed such as room ventilation, safety equipment (BSCs, eyewash stations, spill kits, etc.), and proper specimen transport.

The best approach for this (as with any new process in the lab) is to conduct a complete risk assessment. One method is to identify the risks associated with the new testing, rate the likelihood and consequences of potential hazards in the process, and then implement steps to mitigate those hazards. Performing these assessments routinely and reviewing them will help to keep your staff safe as work continues in the department all year.

The COVID-19 pandemic affected other areas of work in the laboratory. Accreditation agencies delayed inspections, and now they are trying virtual auditing. Staffing levels are affected by virus exposures in the community or within the department, and while organizations do their best to follow national safety guidance, many have different approaches. The pandemic is not over, and soon healthcare workers will be offered a vaccine. What new lessons will we continue to learn as the situation continues to develop? Time will tell. The important thing for lab leadership is to stand for what keeps those in their department safe. Continue to follow standard precautions, and escalate issues when the unusual occurs. Remember, we will get through this, but as we do, take the opportunity to learn from the experience this year and when moving ahead!

Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

The Pathology Value Chain and Global Health

When Michael Porter conceptualized the Value Chain in 1985, histology as an idea was at least 184 years old and the use of a microtome to cut sections was 155 years old. Now 35 years into value chain as an established lens for markets and firms to approach those markets, numerous publications and reports discuss the value chain of diagnostics, of digital pathology, and of laboratories as profit centers from a variety of sources and as a profitable business model. With the core tool—histology—being such an old technology, easily duplicated, and standardized for skill, quality, and output, can it create competitive advantage or be part of a firm’s value chain? The framework of diagnostic anatomic pathology services (for example, a histology diagnosis for cancer) as a profit model creates ethical questions around what the true value of these services are when the tool is so common. No one chooses to have cancer. Therefore, no one chooses to have a diagnostic procedure for cancer. Stated another way, the consumer’s choice for the product is a potential matter of life and death—that is not true of breakfast cereal. One of the most important features of a capital market is free choice by consumers to choose or not choose products and services. Today, there are people that get by with a flip phone that only makes phone calls and perhaps sends text messages while other people choose essentially supercomputers to carry around in their pocket; however, no one is going to die if they don’t have a telephone on their person. Without a diagnostic procedure for cancer—with histology serving as the primary tool—patients will commonly die from that disease; but with a diagnosis they have a chance of cure, a chance which increases greatly the more rapidly and the earlier in the course of disease the diagnosis is made. One paradigm of healthcare that differs from actual business sectors is an inverse relationship of cost to supply. As competition increases in business, prices are driven downward and reach a level barely above margin which sustains the supply of the goods but often requires the business to diversify or innovate to reach higher margins. In healthcare, costs for the same procedures which are standard of care have gone up, year over year, even while new innovations emerge at higher costs. From a business perspective, creating a feasible value chain around healthcare and, specifically histology, seems unlikely to be sustainable in the long run. However, patients are the center of healthcare and there is high value to patients in having services that meet their medical needs. In applying the concept of “value” and established value chain concepts to anatomic pathology, we shall assume that the maximum value the system can achieve is the shortest time interval from development of cancer in the patient to cure. Fortunately, this value lens mirrors the most efficient pathology laboratory system which would process and sign out large volumes of small biopsies. Coincidentally, that is also the best profit model.

Many countries and large segments of the population in general do not have access to diagnostic histology services due to a range of barriers and challenges that are specific to each site. In some instances, these systems simply do not exist, for example, on many island nations and some nations that are less than 2 million people. The reason for this absence in such settings is due to a massive cost of such services because economies of scope and scale cannot be achieved without a particular threshold of case volume which results in excessively expensive—and thus, unsustainable–services. In larger yet low-resourced countries, private diagnostic histology services with variable quality exist with the main barriers being the out-of-pocket costs of those services to patients although quality could be considered the more important barrier. In high income countries, impoverished patients and patients with insufficient insurance coverage may never be able to access services while others who can access services initially may be inundated with bills related to cancer care that lead to financial disaster. However, all of these “gloom-and-doom” anecdotal observations are not solving the large range of problems that can be found across the patient’s pathology value chain. In order to approach this in the spirit with which Michael Porter intended but framed for a patient, let’s look at the pathology value chain with our value being maximum benefit to the patient, frame it in the context of global health, and assign solutions based on the original Porter activities. This is part 1 of a 4-part series dissecting value chain and pathology in global health. The activities are inbound logistics, operations, outbound logistics, marketing & sales, and service. Let us look at inbound logistics in this part.

Inbound Logistics – This activity encompasses the “receiving, warehousing, and inventory control of a company’s raw materials.” For the lens of maximum value to the patient, from the moment a biopsy is taken until delivery to the laboratory should be minimized and, when the sample arrives, it should be able to be processed immediately with all reagents available. For anatomic pathology, this portion of the value chain includes controlled and uncontrolled raw materials. The controlled raw materials are all of the purchased reagents, supplies, and other consumables that are used in the process of histology and include hazardous materials, flammable materials, and bulky materials such that inventory control should be optimized for both maximum efficiency and value but also maximum safety of staff. “Stock outs”, which are relatively rare in high-income settings, on the laboratory side can include lack of any of the essential reagents and tools to process samples including formalin, alcohol, xylene, paraffin, glass slides, cassettes, etc. Stock outs are the most common challenge in LMICs followed by complete lack of supply chain or lost supply chain. In HIC, bulk purchases, long-term contracts, and volume pricing reduce the cost of the controlled raw materials and can create slight competitive advantage.

Uncontrolled raw materials are the inbound patient tissue samples which can range from minute to whole bodies (in the special case of autopsy) and may be “packaged” by a diverse set of suppliers (i.e., clinical teams) with variable resources. These materials are also “precious” in that they are unique to each customer, cannot be easily reobtained, do not have a fiscal loss value that is easily quantifiable, and may have a large impact on the patient from which they are derived. These materials are also “flawed” because the pre-analytic collection of them by individuals that are not part of the laboratory may create inadequate, insufficient, inappropriate, or damaged materials. In HIC, considerable effort goes into educating clinical teams on collection, creating referral networks, providing collection vessels, etc.; yet laboratories still receive inadequate or insufficient samples. When we consider low- and middle-income countries, observed delays/deficiencies in this part of the value chain are quite common. “Stock outs” on the clinical side can include lack of supplies of clinicians for obtaining biopsies from a specific patient such as sterile biopsy tools, surgical services, and adequate formalin. “Skill lacks” include insufficient training or understanding of the laboratory operations by the clinical team to obtain a biopsy from a patient or properly prepare it for delivery to the laboratory. “System lacks” include an absent or poorly functioning specimen transportation and/or communication system which delays or prevents samples from reaching a laboratory. For a given patient or even population of patients that are to be served by a clinical health system feeding to a specific laboratory, the value chain can be massively depreciated if these inbound logistics are not rectified. When encountered and depending on the specific gap in controlled or uncontrolled raw materials, the solutions can include training of clinical staff; local production of reagents; supplier contract negotiations; bulk ordering; collaborative ordering; cost cross-subsidization; public-private partnerships; capital investment in transportation; and coordination with other convenient transportation networks.

To summarize this part, inbound logistics for a pathology laboratory include controlled and uncontrolled raw materials that have variable costs, safety, inherent value, and flaws that must be considered when planning laboratory operations. With rare exception, these inbound logistics are standardized which leaves little opportunity for major competitive advantage. In LMICs, stock outs (complete or delayed) can invalidate the work of a pathology laboratory by creating significant time delays in diagnosis which make the final diagnosis useless to the individual patient and erode the clinical confidence in the overall system.

In part 2, we will look at operations.

References:

Porter, M. (1985). The value chain and competitive advantage, Chapter 2 in Competitive Advantage: Creating and Sustaining Superior Performance. Free Press, New York, 33-61.

Histology. Wikipedia. https://en.wikipedia.org/wiki/Histology#:~:text=In%20the%2019th%20century%20histology,by%20Karl%20Meyer%20in%201819.

Thorpe A et al. The healthcare diagnostics value game. KPMG International. Global Strategy Group. https://assets.kpmg/content/dam/kpmg/xx/pdf/2018/07/the-healthcare-diagnostics-value-game.pdf

Digital Pathology Market CAGR, Value Chain Study, PESTEL Analysis and SWOT Study|Omnyx LLC, 3DHISTECH Ltd, Definiens AG. https://www.pharmiweb.com/press-release/2020-06-30/digital-pathology-market-cagr-value-chain-study-pestel-analysis-and-swot-study-omnyx-llc-3dhistec

Friedman B. The Three Key Components of the Diagnostic Value Chain. Lab Soft News. January 2007. https://labsoftnews.typepad.com/lab_soft_news/2007/01/the_three_eleme.html

XIFIN. The Evolution of Diagnostics: Climbing the Value Chain. January 2020. https://www.xifin.com/resources/blog/202001/evolution-diagnostics-climbing-value-chain

Sommer R. Profiting from Diagnostic Laboratories. November 2011. Seeking alpha. https://seekingalpha.com/article/305931-profiting-from-diagnostic-laboratories#:~:text=The%20three%20year%20average%20operating,current%20operating%20margin%20of%2012.9%25.

milner-small


-Dan Milner, MD, MSc, spent 10 years at Harvard where he taught pathology, microbiology, and infectious disease. He began working in Africa in 1997 as a medical student and has built an international reputation as an expert in cerebral malaria. In his current role as Chief Medical officer of ASCP, he leads all PEPFAR activities as well as the Partners for Cancer Diagnosis and Treatment in Africa Initiative.

A Closer Look at “Inside the Lab”

Hello everyone and welcome back!

If you’re as “plugged in” to the pathology and laboratory medicine community as I am, then you’ve been absolutely swimming in the explosion of new content and novel delivery this past year alone! A lot of it is a result of our unfortunate pandemic circumstance, but the pathology media-train has been gaining speed for quite a while now.  Whether you’re a podcast addict, an enthusiastic virtual annual meeting participant (which is still open!), or if you’ve spent way too much time on Path Twitter, I’m right there with you!

Image 1. Awesome Title. Awesome Topics. Awesome Podcast. Subscribe today!

I’ve talked here before about the power and impact of social media in our community, and I could drone on and on about its impressive potential and warn you about pitfalls, give you tips, or just celebrate success stories. But that’s boring. You may or may not have a social media presence, in which case I’d either be pandering to the choir, or putting you sound asleep. Well, I didn’t match into anesthesia, so let me give you the readers’ (tweeters’?) digest. ASCP has (yet again) taken a huge stride in making a presence in today’s increasingly digital age. Catalyzed by many things—pandemic included—many of the projects I have heard about among ASCP colleagues have started to magically materialize; enter the podcast. Among podcast media, ASCP’s Inside the Lab absolutely nails the archetype of what good podcasting is today! It’s a wonderfully curated series, highlighting super relevant topics, and is hosted by a fantastic team. But that’s not all! (wait, this sounds like a commercial, I’m drafting an email about promotional royalties right now…) Kidding. Sort of. Along with the topics, discussions, and guest panelists in the 7 episodes thus far, you can get continuing education credits!

Let me stop there. For emphasis. Imagine you’re driving to work. Sipping your coffee, sitting through traffic on the Dan Ryan Expressway (to those not in Chicago, we name them—we can talk more about this later). You suddenly remember you need CME/CMLE credits for your continuing ed maintenance. Great, you’ll just go hunting online for some boring QA/QC module about something somewhat related to your interests. Or… you could pop in those air pods and turn this podcast on for 1 AMA PRA credit a piece! Leave the murder mystery podcast for the drive home and spend the morning Inside the Lab! But I promised the readers’ digest, right? The following are highlights from a few of the currently available episodes for your listening and CE registering pleasure…

Image 2. Can’t have a good show, without good hosts. Dr. Milner, Dr. Mulder, and Kelly Swails are just that: excellent hosts and fantastic conversationalists who bring up interesting topics that go deeper into pathology and laboratory medicine. It makes for easy listening, easier CE, and provides the listener with a nice peek Inside the Lab. (Oh man, see what I did there?)

Hosted by Dr. Danny Milner (ASCP Chief Medical Officer and Global Health Champion), Dr. Lotte Mulder (ASCP Leadership and Empowerment extraordinaire), and Lablogatory’s very own Kelly Swails (digital managing editor in publications); the podcast has featured numerous amazing guests and topics ranging from testing logistics and interprofessional collaboration, to burnout and (obviously) COVID.

Episode 1: Disparities in COVID Cases Among Minorities

The inaugural episode featured Dr. Von Samedi (Associate Professor of Pathology at the University of Colorado School of Medicine), Dr. Valerie Fitzhugh (Associate Professor/Interim Chair of Pathology and Laboratory Medicine at Rutgers), and ASCP Social Media teammate Aaron Odegard (Infectious Disease MLS at Baptist Health Jacksonville). The inaugural topic (not a softball by any measure): how Black, Latinx, and minorities have suffered the brunt of COVID worse than other demographics. They discussed how COVID, at large, has uncovered swaths of long-standing, problematic disparities, and failures of our healthcare system. I gave a lecture on this topic when I was in New York as part of a CDC-funded, public health training seminar back in April of this (super long) year and things haven’t gotten any better—in fact from April to August when this episode aired, cases absolutely skyrocketed, especially in minority populations. The discussion’s bottom line: our community stands at a crossroads of education and delivery of results to both change the paradigm and improve the system. Good stuff. Listen here.

Episode 3: Online Teaching and Learning in Pathology and Laboratory Medicine

This cutting-edge episode featured our hosts talking to Dr. Sara Wobker (Assistant Professor in Pathology and Laboratory Medicine at UNC Chapel Hill), Dr. Natalie Banet (Assistant Professor of Pathology and Laboratory Medicine at Brown University), and Dr. Richard Davis (Regional Director of Microbiology for Providence Health Care in WA). The topic: how the pandemic has shunted all educational efforts into zoom meetings, virtual conferences, and online classes. Maybe this was happening already? The panelists talked about the old guard of education and the new way online learning has provided dynamic, flexible options for various students of all learning styles. Limitations, however, are clear when addressing pathology education—it’s not so easy to go virtual overnight and you can see the growing pains in every laboratory department. When you try to deliver old lessons across new platforms, things don’t work. So, in order to maintain relevance, engagement, and success educators must take into consideration different types of students, social determinants of learning, cultural backgrounds, accessibility, and inclusion for all. Highly relevant today. Listen here.

Episode 6: Pathology Research and Publication

Finally, I’ll end with a more recent episode. This one featured a panel that included (among their many other academic and clinical roles) Dr. Steven Kroft (Editor-in-Chief of the American Journal of Clinical Pathology), Dr. Roger Bertholf (Editor-in-Chief of Laboratory Medicine), and Dr. Sanjay Mukhopadyay (Associate Editor of the American Journal of Clinical Pathology). The topic for these well-published leaders in our field: how important it is to maintain a scientific standard, and how to get your paper published—yes you! They all talked about peer review, editing, submitting, and being able to tell whether paper’s are “good.” A seemingly subjective measure, but apropos of the year we’ve had which was filled with so many “bad” pieces of scientific literature. The benefits and limitations of peer-review are something we all have come to scrutinize as the digital age puts out clinical content ad nauseum on our social media feeds. But they all assert that one thing should be preserved as the future of scientific publication unfolds: the ability to create a standard by which professional societies, and medical subgroups and communities, collect and assess the science behind our work with purpose, accuracy, efficacy, and efficiency. It behooves editors as well as writers to enter a process that, ultimately, aims to improve the system as a whole—for the benefit of patients everywhere. Exactly how we are #StrongerTogether. Check it out here.

Image 3. You’re still here. It’s over. Go home. Go. Go listen to the podcast. Get your CE!

Check out these and the rest of the available episodes at www.ascp.org/insidethelab, Apple’s app store, Spotify, Google play, or wherever you listen to podcasts!

Thanks for reading, now go listen!

See you next time!

Constantine E. Kanakis MD, MSc, MLS(ASCP)CM is a first-year resident physician in the Pathology and Laboratory Medicine Department at Loyola University Medical Center in Chicago with interests in hematopathology, transfusion medicine, bioethics, public health, and graphic medicine. He is a certified CAP inspector, holds an ASCP LMU certificate, and xxx. He was named on the 2017 ASCP Forty Under 40 list, The Pathologist magazine’s 2020 Power List and serves on ASCP’s Commission for Continuing Professional Development, Social Media Committee, and Patient Champions Advisory Board. He was featured in several online forums during the peak of the COVID pandemic discussing laboratory-related testing considerations, delivered a TEDx talk called “Unrecognizable Medicine,” and sits on the Auxiliary Board of the American Red Cross in Illinois. Dr. Kanakis is active on social media; follow him at @CEKanakisMD.

The Lab Safety Professional: How to Grow Your Role

In any professional career path, there are people who want to learn, to grow, and to advance professionally. That’s no different in the world of laboratory safety, and there are good opportunities to make that happen. If you’ve been in your position for a while, you might be asking what the purpose is for growing in your role. There are good reasons, and there are easy ways to go about it as well.

One reason to advance yourself professionally in the role of lab safety is that it can help you to stay on top of the latest regulations. That, in turn, will help you do a better job with keeping your lab safe and up to date, a goal we should all have. Advancement in the role can also keep you excited and motivated about your career which may make you a stronger safety leader. That motivation can lead to involvement with other laboratorians and professional organizations which creates advocacy for lab medicine (and safety) as a whole. Those interactions have the potential to bring positive changes to the overall field of lab safety. Embarking on the road to professional growth in lab safety also has personal benefits. It keeps you from becoming stagnant in your job. Armed with the latest information and making positive changes to keep your safety program running strong, the professional growth may lead to new and exciting career opportunities that did not previously exist.

Staying on top of changes and news in the world of lab safety is important to keeping your safety program up to date and in compliance with the latest regulations. It can be difficult sometimes to find the time to read professional articles or newsletters, but if you learn to skim headlines and read the relevant material, you can remain aware of new or updated safety regulations. There is an abundance of free literature available, and there are even safety and occupational health resources that are not specific for labs, but which contain valuable safety information on topics like PPE, the physical environment, ergonomics, or waste management. Request free newsletters from important safety resources such as OSHA, the CDC and NIOSH. These organizations have a major impact on lab safety guidelines and regulations.

Knowing your written and published laboratory safety resources is important as well. The Laboratory Biosafety Manual is a free book available from the World Health Organization (WHO) website. The latest version is the 3rd edition, and it was published in 2004, but an updated version will be released soon. The CDC’s Biosafety in Microbiological and Biomedical Laboratories (BMBL) 5th Edition is an excellent resource for biosafety information, and its next edition is also due to be published soon. OSHA offers a Laboratory Safety Guidance book on line as well, and the information withing aids in obtaining compliance with safety regulations that are required in all labs.

Another way to become more actively involved in lab safety is to volunteer to write or edit CLSI lab safety guidelines. The Clinical & Laboratory Standards Institute (CLSI) accepts volunteers from government, industry, and clinical labs to assist with guideline development, editing, and approval. Through their process, you can work on teams to create best safety practices that are viewed around the world. The experience of working with other lab safety professionals will broaden your knowledge and expand the resources you now access. Being a part of the CLSI document development process is a worthwhile and professionally rewarding experience.

Lastly, a lab safety professional can grow their role through certification. There are some general safety certifications that can be achieved, but there is only one in the United States that is specific to clinical lab safety: The Qualification in Laboratory Safety (QLS) offered by ASCP. The process of applying, studying, and testing for this certification can take you to that next level of lab-specific safety knowledge and expertise. The certification also bestows upon you increased credibility as an expert. If you have some experience in your role and are looking for the next step, getting that ASCP QLS is for you.

There are those who might think a career in safety sounds boring, and a narrower focus on clinical lab safety may even appear to be limiting as a career choice. That is not the case – there are a wide variety of methods to grow in such a career and truly become an experienced professional who is well-respected. That respect can take your career down an amazing path you never thought possible, and such a path can only be a benefit lab professional everywhere.

Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Virtually Amazing

Hello everyone and welcome back!

I’ve appreciated some amazing feedback from my previous post discussing how doctors can sometimes be patients too, and the challenges one might face in different roles within our health care system. Not only a challenge of roles, but those that struggle with invisible illness have unique perspectives on patient care.

That said, this month let me take a break from all the fun content found between cases, concepts, and trends in pathology and laboratory medicine, and celebrate our amazingly successful (and virtual) Annual ASCP Meeting!

Image 1. Just look at this virtual lobby! Set aside that in-person connectivity dissapointment and just appreciate the quality put into this visually! More of my oggling to come in further images…

It was awesome. But don’t just take my word for it, we’re all people of science here, right? So let’s do it by the numbers!

  • 133 educational sessions
  • 3 general sessions
  • 4 named lectures
  • 36 round table sessions which included topics like wellness, problem-solving, collaborative solutions, and “birds of a feather” breakout discussions
  • 9 virtual video microscopy sessions
  • 8 session dedicated to laboratory professionals covering hematology, chemistry, microbiology, and blood banking
  • 6 resident board review sessions
  • 15 companion society sessions
  • 14 sessions related to wellness
  • 4 sessions discussing diversity and inclusion
  • 10 COVID-focused sessions
  • 20 grant funded sessions
  • 4 virtual patient symposia (more on this topic below…) and
  • And 300+ posters!
Image 2. More visual appreciation here: virtual sessions felt like you were really in a large, collective meeting of enthusiastic, like-minded laboratory professionals all learning, collaborating, and networking together!
Image 3. I was fortunate enough to to speak on this amazing panel regarding direct patient-and-pathologist interactions, making laboratory medicine and the overal healthcare experience, safer, more accessible, more interdisciplinary, and better equiped at dealing with the forefront of medical diagnostics!
Image 4. So, the session went well! Just look at that social media data: 36 million impressions over 3.5 days! That’s 1 million people engaging ASCP topics a day, or 12 people per second! All actively discussing and collaborating topics in pathology and laboratory medicine.
Image 5. How could I (of all people) ignore the fact that #ASCP2020 featured an amazing social (media) lounge where people from all over could connect, chat, network, and relax! There were interactive, virtual sessions covering all kinds of non-lab med stuff: yoga, meditation, mixology, and cooking! I hope this is a permanent addition to future (hopefully) hybrid in-person/virtual meetings.

What more could you ask for? The folks that run the logistics and planning for the ASCP Annual Meeting outdid themselves again. Sure this content would excite anyone in the field for 3 dedicated days of immersive learning and networking, but all this and more are still available online for virtual on-demand recorded viewing! Missed a session? No worries, it’s still waiting for you for about 6 months (through March of 2021). All the buzz aside from ASCP members having free access to all of this content, the excitement started months before the meeting went live. Estimates are still coming in, but membership grew by a couple hundred in the weeks leading up to the meeting—not surprising: free access for members? That was an excellent deal, so choice.

Image 6. The start of the #ASCPSoMeTeam’s amazing trajectory culminated at #ASCP2019 in Arizona, the more we work together the more we can accomplish for our profession and our patients, #StrongerTogether.
Image 7. ASCP’s Resident & Pathologist Councils are invaluable assets to promoting and advancing all of our professional development. #ASCP2020 was no different! From virtual fellowship fairs to online, interactive resident council sessions, there was a lot to take it—still available online!
Image 8. I’ve talked about previous ASCP Annual Meetings here and here, and while I can’t list every single aspect of what made this meeting (virtually) amazing, members can check in for about 6 months and see for themselves the quality and attention to detail that comes directly from our collective passion to make pathology and laboratory medicine better, for everyone. Kudos to the ASCP leadership and logistics teams that made this all possible!

Great to see you all at the meeting!

Thanks for reading! See you next time!


-Constantine E. Kanakis MD, MSc, MLS (ASCP)CM is a new first year resident physician in the Pathology and Laboratory Medicine Department at Loyola University Medical Center in Chicago with interests in hematopathology, transfusion medicine, bioethics, public health, and graphic medicine. His posts focus on the broader issues important to the practice of clinical laboratory medicine and their applications to global/public health, outreach/education, and advancing medical science. He is actively involved in public health and education, advocating for visibility and advancement of pathology and lab medicine. Watch his TEDx talk entitled “Unrecognizable Medicine” and follow him on Twitter @CEKanakisMD.

Safety Checklists and High Reliability in the Lab

A High Reliability Organization (HRO) is one that works with complex and hazardous systems every day and yet retains a high level of safety and an error free environment. The first recognized HRO industries were the United States Navy nuclear aircraft carriers , the Federal Aviation Administration’s Air Traffic Control systems, and nuclear power plant operations. These industries operate using highly complicated and dangerous processes, yet they have the fewest safety incidents.

The use of checklists is an important part of keeping safety incidents to a minimum. They can help employees avoid safety issues, avert disasters, and even aid in incident response. In aviation, a pre-flight safety checklist is a list of tasks that must be performed by pilots and crew before a take-off. Pilots also use checklists for both normal and non-normal operations, for landings, take-offs, and also for malfunctions, and emergencies. Checklists are usually printed on a card, and one card may be divided into as many as a dozen of separate checklists, each of which will be read aloud depending on the phase of a flight. Nuclear power plant operations also involve the use of many safety checklists.

A functional safety checklist features specific characteristics that aid the user in avoiding safety mishaps. Checklists should have defined pause points so users can determine when the list should be used and when new tasks should begin. Checklists types are also important, and the style used may vary depending on the task and the experience of the user. For example, a “do-confirm” list is generally used when users are experienced with the process and have gone through the necessary steps on the list and simply run through it to ensure the process is complete. A “read-do” checklist means employees perform the tasks as they read through each list item.

Most checklists should not be lengthy as it may tempt experienced users to take shortcuts or to ‘pencil-whip’ responses. Make sure the list includes crucial and potentially overlooked steps. These may be the things that can cause the greatest harm if not checked. Use language that is simple, precise, and use terminology that is familiar to the lab staff using the list. Lastly. Test the checklist to see that it fits the criteria above, and that it accomplishes the task set for it. The real goal of using a safety checklist is to create a cultural change by enhancing teamwork, increasing safety communication and changing the understanding of responsibility for safety within the department.

There are quite a few published lab safety checklists available for use. Here are just a few:

  • CLSI’s Clinical Laboratory Safety (GP-17) – Lab Safety Checklist (Appendix C)
  • World Health Organization Biosafety Manual (2004)– Ch. 22 Safety Checklist
  • ISO 15190 Medical laboratories: Requirements for Safety (2019) – Annex B
  • EPA website: Waste Generator Inspection Checklists

Your lab may have its own specific needs, and these checklists may not cover them, or they may be too much for your current issues. If that is the case, create a checklist that focuses on an issue or issues you’d like changed. For example, if PPE compliance is on the rise, create a list that can be used daily or weekly. Walk around and look for proper footwear, lab coat use, and face protection for example. Home made checklists can be scored and used as a quality monitor in order to show improvement in lab safety over time. Make sure people are trained to use the checklists properly, and that people are consistent in how they answer individual items. It’s always a good idea to alter who uses the safety checklists as well. Make sure everyone can use them, and that will create a broader understanding of the safety needs of the department. That can go a long way toward improving the overall safety culture. A review of checklists is always key. If there is a problem with a response for a particular item, it should never be ignored. In fact, it should be addressed quickly.

Many labs today do not fall into the category of a High Reliability Organization. Complex and dangerous tasks do occur in the field, but safety incidents are not uncommon. It may be because lab employees are not educated enough about the consequences. There are definite hazards when working in the lab setting, but often they are not in the forefront of the lab techs’ minds, safety is not made a priority. It needs to be discussed more. Or maybe the reason is that many of the hazards in the lab do not always have more immediate consequences. Organisms involved with exposures have incubation periods, and disease states (like cancer) can take years to develop after a safety incident.

In the airline and nuclear industries, if a safety error is made, the consequence is usually immediate, and deadly for many. Is that it? Is that why people don’t have the same reaction to safety issues in the lab? What can we do as safety professionals to change that? I believe we can change it- and it will take checklists, training and safety awareness.

Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Floating in a Sea of Uncertainty: Finding a Lifeboat

As we all find ourselves 9 months into 2020, which is arguably the worst year in living memory for many people, we face daily ongoing challenges of completing our work, finding work, adapting our work, feeding our children, schooling our children, preserving our health, caring for loved ones, and trying to not let the daily stress piped in from every communication channel send us over the edge. There are many people who have had a stellar year and have become richer beyond anyone’s imagining as the multitude of crises have fed their business models. There are many people we have lost prematurely due to an uncontrolled viral plague who would have contributed so much had they lived. Amidst all of this, there are individuals dealing with everyday problems in the chaotic setting of 2020—cancer, mental illness, disability, disparities, financial burdens, etc. Personally, I have a dear friend who was on the brink of a complete mental breakdown in 2019 for who I now feel I am on suicide watch 24/7. Life is normally hard, but it has certainly been abnormally hard for the past 9 months. I do not wish to point fingers, place blame, use hindsight, or make astute observations that are of no value—what my sports colleagues call the Monday quarterback effect. What I do want to do is open up to anyone reading this with a few of the things I have done in the last 9 months that have provided comfort and reminded me that, “This too shall pass.”

Take a stroll down memory lane – When I was younger, I used to take a lot of photographs with an actual camera and film. I would probably pass out if I knew exactly how much money I have spent in my life on buying and developing film. My dad was also an amazing photographer and probably knew more about taking traditional photographs than I know about infectious disease. During a certain period (end of high school through the beginning of residency – about 10 years), I was always taking photos and had at least three cameras all the time: a polaroid, an SLR, and point-and-shoot. I was not a very good photographer overall and most people quickly got annoyed with my constant snapping. But I am a collector so every photo I took was placed in an album. In organizing my garage on a Saturday recently when I was looking for anything to do because there was nothing really to do socially outside of my home, I made the decision to reorganize all of my photos into boxes by year and/or event and get rid of the photo albums. I do not recommend that unless you have a lot of time on your hands. But what I do recommend, and I greatly enjoyed, was going through EVERY photograph in my collection. There is a small box from when I was young that were taken by others as well as high school. There is a small box from college. There are literally 12 boxes from medical school and 6 boxes of my family. What did that mean in reality? I was incredibly happy in medical school. I remember being unhappy in high school and college. I have only a handful of friends each from high school, college, and medical school that I am in contact with regularly so no bias in that regard. But I wanted to remember medical school to a much greater degree than I had college or high school. My family is similar as I love my family. Seeing pictures of my grand parents who have all passed and my little cousins before they became grandparents made me feel happy and nostalgic. You have got photos somewhere (and I don’t mean the loads of ridiculous selfies on your Facebook account). Go dig them out and flip through them. If you find some true gems, post them on your social media. Share your memories and you will naturally smile.

Learn something new – We are inundated with information constantly but most of it is not knowledge. Most of it is simply status—the current state of people around us, all of whom will be dead and dust one day. One of my favorite lines from “The Terminator” is, “Look at it this way… In a hundred years, who’s gonna care?” All the tweets, all the posts, all the photos are fleeting moments of fluff (and probably rot your brain—scientific studies to be complete). But knowledge is forever and is precious. Do you know how to refinish an old piece of furniture? Do you know how to grow any type of plant from a cutting? When is the next time we will see Saturn chasing Jupiter across the sky? What happens to stuff you put in a recycling bin? Where does the electricity you use in your home come from? Can you name all 80 unique cultures in Ethiopia? The internet is full of a lot of garbage, but it is also full of incredible sources of knowledge. Sometimes (most of the time) we are so tired of looking at a computer or a smartphone or a tablet if we are working remotely that the last thing we want to do is engage with it further. Libraries are open so you can always resort to dusty old books which are also full of knowledge. Online classes are available for many things. Although cliché, TED talks can be cool. If you are feeling overwhelmed by all of the negativity, opinions, and bandwidth that’s given to things no one will care about in 100 years, turn your attention towards something pure and lose yourself in the nonpolitical world of knowledge. An expert is someone who knows everything that is true about a subject as well as everything that is false. Pick a topic, preferably something that does not come up in your work and set a goal to become an expert in that topic. There will always be people who know more than you do on any topic—but not every topic—but the point is to gain knowledge, grow your brain, and appreciate the permanence of truth.

Mindfulness, it’s really NOT a fad – I wouldn’t dare try to completely address the topic of mindfulness in a short blog, but I will challenge you to investigate it for yourself. Where my last suggestion is one to fill your brain with new ideas, information, processes, and thoughts so you master something external to yourself, mindfulness is the exact opposite. Learning to “turn your brain off” is an amazing skill that does take practice but has enormous benefits. And it is not really turning your brain off but rather turning down the volume on all the negative thoughts you have and may not even know it. Negative thoughts—internal or external—do not control you! They are your thoughts and the most powerful thing you can do is control them. There are many books on this subject, but my favorite is, “Mindfulness: An Eight-week Plan for Finding Peace in a Frantic World”. I will not lie to you. I read this book 5 years ago and have been practicing the techniques since then which did give me a leg up on the horror hurricane that is 2020. But it is never too late to reach inside yourself and find inner strength to deal with outer challenges. It is a bargain at less than $15 and will give you some amazing tools to use if you give it a chance. On a side note, if you are dealing with mental illness or you have a loved one who is dealing with mental illness, the most important first step is recognition, acceptance, and treatment. No one can be expected to defeat the external demons of the world when your internal demons have the chemical advantage. Recognize the signs and recognize the external amplifiers so you can be the hero for those who need you most during this time.

You’ve got to have friends – I remember in the not too distant past listening to “old people” say, “These darn kids need to stop playing video games and texting friends in the same room and get outside and play.” True? Yes. But now our reality has shifted to digital communications as the safest way to go to work, go to school, and see our friends. Zoom parties and the like have become extremely popular and I wrote about etiquette for these tools previously. But they are not the only way to communicate. Did you know that your smartphone is a phone? You can call and talk to people! All that paper junk mail that shows up in your snail mailbox is bidirectional. You can send people letters! This is all obvious and the vast majority if not all of you reading this have used some form of communication to talk to non-work people at least once in the last 24 hours. But do not take this for granted. There were people before our virally induced confinement that did not have large social networks or even limited ones. The isolation of our current situation is amplifying their loneliness. What am I asking you to do? You have a phone. You have social media. Dig through your contacts, find someone you have not talked to in a while, and reach out. Check on them. Check on your distant family members. Ask about them, how they are doing, and what is new in their life. Hearing their voice and laughing with them will make you smile on the inside and the outside.

Move – Your body. Daily.

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-Dan Milner, MD, MSc, spent 10 years at Harvard where he taught pathology, microbiology, and infectious disease. He began working in Africa in 1997 as a medical student and has built an international reputation as an expert in cerebral malaria. In his current role as Chief Medical officer of ASCP, he leads all PEPFAR activities as well as the Partners for Cancer Diagnosis and Treatment in Africa Initiative.

False Negatives in COVID-19 Testing

I left for vacation at the beginning of June thinking “once I get back, all of this COVID stuff will be quieted down.” …Well that wasn’t quite the case and testing for novel Coronavirus has continued to be very important. In fact, this last weekend I was tested by occupational health. It came back negative, but I’m am very enthusiastic to get alternative specimen types validated; those Nasopharyngeal swabs are quite…uncomfortable. Luckily, my test was processed at our institution which gets results back in 24-48 hours. However, with the resurgence around the country, turnaround times are backing up to 7-8 days. One solution has been the widely used IDNOW point of care platform. However, there has been significant concern over false negatives produced by this platform. One reason the sensitivity is different is because this platform performs isothermal amplification of nucleic acid. This method amplifies RNA at a stable temperature instead of cycling the temperature as in real-time PCR.

Colleagues at my institution reflexed any negative IDNOW samples to the m2000 Real-Time PCR assay for SARS-CoV-2 for one month. Within that time, over 500 samples were tested and the IDNOW was found to have missed 21% of positive cases (prevalence rate of 5%)2. One the positive side, it had a 98% negative predictive value, which helped rule out COVID19 infection. However, as prevalence rates are increasing, a high negative predictive value isn’t as important as sensitivity.

One study drew much attention when it claimed the IDNOW had a sensitivity of 52% in a New York City academic institution (Basu)4. However, this seems to be an outlier compared to other studies of this platform: one large multi-center study found positive percent agreement (equivalent of sensitivity when a gold standard test hasn’t been established) of 74%1. The highest PPA of 88%3 for the IDNOW was found in a study that indicated it can be completed in 17 minutes, whereas another quick instrument (but not point of care instrument: Xpert Xpress, 45min) had a PPA of 98%2.

Myself and other colleagues looked more closely at the clinical characteristics of false negative test results on the IDNOW. Overall, we found 82% PPA, and 8 patients with false negative tests. Interestingly, a majority of these patients were tested over 2 weeks after their initial onset of symptoms. The virus is known to be at its highest levels at the beginning of symptom onset. So the test may not be limited, but it should be used in the correct clinical context (< 2weeks from symptom onset). After that time, other RT-PCR based tests are more appropriate.

As clinical laboratorians, we often hear: “the right test for the right patient at the right time.” Now with so many platforms available for use in different contexts, we should help guide clinicians to Choose Wisely.

References

  1. Harrington A et al. Comparison of Abbott ID Now and Abbott m2000 methods for the detection of SARS-CoV-2 from nasopharyngeal and nasal swabs from symptomatic patients. JCM 2020. PMID: PMID: 32327448
  2. McDonald et al. Diagnostic Performance of a Rapid Point of Care Test for SARS-CoV-2 in an Urban ED Setting. Academ. Emerg. Med. 2020. PMID: 32492760
  3. Zhen W et al. Clinical Evaluation of Three Sample-To-Answer Platforms for the Detection of SARS-CoV-2. JCM 2020. PMID: 32332061
  4. Basu A et al. Performance of the rapid Nucleic Acid Amplification by Abbott ID NOW COVID-19 in nasopharyngeal swabs transported in viral media and dry nasal swabs, in a New York City academic institution. BioRxiv 2020.

-Jeff SoRelle, MD is a Chief Resident of Pathology at the University of Texas Southwestern Medical Center in Dallas, TX. His clinical research interests include understanding how the lab intersects with transgender healthcare and improving genetic variant interpretation.

The Laboratory’s Role in Inclusion

“Where do we go from here…chaos or community?” is the question Dr. Martin Luther King, Jr. asked in 1967 before the civil rights riots in the hot summer of 1968.  The query was directed to the nation as it sought to address the racism and pain deeply felt in the daily lives of its African-American citizens.  Over 50 years later, that very same question is asked again as the nation is roiled with civil demonstrations, daily videos of racist behavior, and the seemingly senseless killings of African-American men and women. 

As American culture and the nation evolves, uncomfortable conversations are beginning to occur in healthcare and across the country.  Laboratory administrators and managers may want to reflect on the culture of their laboratory to ensure all voices are heard and that they are creating and supporting an inclusive work environment.

Diversity, inclusivity, and equity are goals healthcare organizations seek to incorporate into their culture to foster a healthy workplace environment and be reflective of the communities they serve.  As with most industries, the laboratory has found itself challenged to improve cross-cultural intelligence and eliminate implicit and unconscious bias.  The scientific community would like to believe it operates and makes decisions based solely on objectivity and facts.  However, everyone is human and prone to perceptions influenced by preconceived beliefs and life experiences. 

In the laboratory, questions involving race relations are pondered and discussed by workers of all creeds and colors.  Historically, laboratorians have viewed themselves as scientists focused strictly on the pursuit of facts, hard data, and helping patients.  However, one would err in thinking the lives of minority lab workers were encased in impenetrable bubbles of logic and reason. Instead, early on in their career (correction—their lives), many minority workers learned to compartmentalize and hide feelings of unfairness and helplessness in their effort to “fit in” and not make others feel uncomfortable.

Laboratory administrators should let employees know that their office is a “safe place” if an employee feels he or she needs to discuss issues affecting how they feel about their work environment. Many employees of color working in predominately white environments may avoid conversations involving race out of fear as being labeled as “one of those.”  However, avoiding difficult conversations does not make the problems go away; in fact, the lack of addressing an issue often creates a more significant problem later on, or the employee simply quits.  One thing managers should be prepared to hear if they are successful in creating a safe space and the employee chooses to talk, harsh truths.

Lab managers can be proactive and ask if the employee has encountered any barriers or obstacles to their success in the healthcare organization.  Minority employees frequently experience microaggressions, favoritism, and racial discrimination.  Discussing feelings may provide a release for the employee, allow the manager to begin to understand, and offer the opportunity for the manager to reflect on their behavior. 

 The diversity of today’s protest marchers provides evidence of the progress America has made toward vanquishing the problems of racism and discrimination.  All colors, creeds, and ethnicities are together expressing their desire to defeat the scourge of racial injustice.  Laboratories are a part of the social community, and minority employees are often reluctant to share anxiety and experiences they feel are race-based.  Lab managers should be reflective and reach out to their employees to let them know their office is a “safe place” to discuss issues openly, including those with racial overtones.  It is only through open and honest dialogue that we can avoid chaos and become the community we seek.

Darryl Elzie, PsyD, MHA, MT(ASCP), CQA(ASQ), has been an ASCP Medical Technologist for over 30 years and has been performing CAP inspections for 15+ years. Dr. Elzie provides laboratory quality oversight for four hospitals, one ambulatory care center, and supports laboratory quality initiatives throughout the Sentara Healthcare system.