Pushing Glass-Change of Season

Discovery

The workflow at ULS appeared unchanged. Mountains of flats with slides were piled to the point of teetering on the pathologists' desks and in histology. Angry client calls initiating numerous client alerts inundated the telephone systems. The continual staff turnover was a nightmare for human resources; by the time new nameplates for new employees arrived, they had resigned their positions.

New faces were not an uncommon sight, but these new teams of men and women immediately made their presence known. ULS, Moynihan, and the plaintiff's attorneys had dispatched their experts to dissect the details of the incorrect report. Each team seized a conference room and littered each table with reams of papers and folders, interrupted by laptops. Various employees were asked to meet with each team. After several minutes of questioning, they were allowed to return to their duties but forbidden to share what was discussed. A daily ritual followed with interviewed employees meeting in the back parking lot of ULS to compare notes.

Everyone in the laboratory was familiar with the case and had formulated their own version. The prevailing opinion was the Memorial pathologists mixed up the slides and gave the patient an incorrect cancer diagnosis. Upper management openly bemoaned the ineptitude that led to this latest debacle. Collins, the lab manager, was particularly vocal. Before the initial contractual arrangement was signed between Memorial and ULS, three years earlier, Collins was joined by the CFO Bryston who both pointed out the increased liability of using residents in training. Assurances were given by both Carlisle and Memorial administration that no resident would primarily sign out a case but would always be overseen by an attending physician. Despite these assurances, the two continued to use any glitch as an excuse to denigrate the Memorial alliance. Collins enthusiastically aided in the investigation, producing data that documented the prolonged response time of the pathologists to answer clinician's complaints. For him, it was compelling evidence that Nomura and the Memorial pathologists cared little for the ULS clients. Bryston undermined support by hammering away at the significant cost of contracting with Memorial pathologists. Carlisle was willing to pay a premium to gain the reputation and expertise of Memorial's pathologists for ULS. Bryston felt this decision was misguided; clients would still utilize ULS regardless of the pathologists who signed out their cases. He was in favor of contracting with non-academic pathology groups, who would be willing to work for far less. The ULS Tampa laboratory paid their contracted pathology group 30% less than St. Louis. Bryston now sensed an opportunity.

"Gene. We've been going through this internal investigation for two weeks now. I've been keeping a close tab on overtime costs and as well as productivity per FTE. We're running 15% over on the overtime and productivity has decreased as well." Bryston presented three sets of charts to Carlisle.

"I suspected as much, " Carlisle shuffled through the papers. "Last thing we need is another lawsuit."

Bryston nodded. "We were reamed four years ago on those liver function tests. But this is the first time we've been sued for a biopsy result."

"I know. Nomura and the others have done a lot to improve things. Too bad this had to happen."

"Yes, too bad." Bryston maneuvered."What was that pathologists' name, the guy who was our director before Nomura? Sak...Saklin-"

"Saxson."

"That's it, Saxson. Henry Saxson, right? Too bad he retired. Those guys were great. Class act."

"Indeed, " Carlisle nodded. "Class act. Remember when they set up that karaoke machine in the lobby during Christmas? I never heard anything so funny. All dressed up like Santa and elves. What did they hand out?"

"Stockings full of candy."

"And there was a card signed by each of the pathologists. The staff loved them." Carlisle leaned back in his chair and repeated the wistful phrase, "Yup, class act."

Bryston sat in the chair in front of Carlisle's desk and lowered his voice. "It's been difficult to get Nomura to cooperate with the investigation. He's being passive-aggressive. Doesn't return my emails or phone calls. The ULS attorneys are incensed by his attitude."

"Really? I hadn't heard that, in fact, I just spoke to Bernstein yesterday. He said the investigation was proceeding on schedule."

"Gene, trust me. It's the same way he treats all of us and our clients. He puts off the problems until they explode and then he blames others. I hate his crisis management style."

"Nomura may not be outspoken but he is efficient. The dermatologists certainly love him."

"Of course, they do. But who else? Certainly not the surgeons in Ladue. They've stopped sending us their cases. That was a $2 million dollar account."

"I know. I've been talking their medical director. He's dropped hints of an audit of our cases. I think they're sending their cases to the Riverside group now."

"Hartman is the director there. I spoke to him. He's young, enthusiastic, has four pathologists working under him. They've been going after surgicenter contracts, picked up two last year. They know how to do high volume outpatient pathology."

"We'll have to keep a closer eye on our pathologists. We've let that slide for awhile, guess we've become complacent about surgical path, relied upon their reputation, devoted our resources to the clinical lab."

Bryston stood up from the chair and pointed at the charts. "Think about Hartman. He's expressed an interest in our contract."

Carlisle nodded. "We'll see."

Nomura had been reassigned to ULS to assist in the investigation. A chilly atmosphere now greeted him. Requests for older biopsy slides to be pulled were ignored. Nomura spent much of his time hunting through the metal files next to histology for the slides he needed. Complaints to Collins went unheeded. The experts for ULS and Moynihan stole away any remaining free time. A common site was Nomura leaving at 9PM in the evening.

Moynihan's information system's expert, Thompson, was intrigued by the ULS LIS or laboratory information system. "Dinosaur" was a word he frequently muttered as he reviewed the system and traced the path of a surgical biopsy report. The LIS was optimized to report clinical laboratory data to physician’s offices. This same system, so competent in delivering laboratory data, was woefully inept at delivering biopsy and Pap smear results. Anatomic pathology was the poor stepchild to clinical pathology. Today, he was concerned about a more serious issue than a cumbersome interface.

"I need to speak with you about the LIS and your protocols."

Nomura motioned to him to sit down. "Go ahead."

"I wanted to run this by you first before I presented it to Collins and the ULS lawyers. Are you aware that transcribers can make corrections or changes to a biopsy report, after it has been signed out and finalled?"

"Of course, it happens all the time. A doctor's office will call in and tell us they gave us the wrong site, change it from left to right, something like that."

"And do you sign off on that corrected report?"

"Always."

"Wrong. Not always."

"Wrong?"

Thompson presented photocopies of the biopsy report from Jackson. "These are photocopies I retrieved from our files. Here is the original report, I've labeled A. Now, look at this second report, I've labeled B. Someone hand wrote a note indicating that Pearl from Ladue Surgicenter called and said the sites were wrong, it should have been left breast instead of the originally reported right breast. So the transcriber changed the sites and issued a corrected report. You didn't sign off on this and there is no record that you approved the change."

Nomura stared at the reports. "How could this happen? These are not the reports that I reviewed."

"I know. The final report you reviewed never mentioned that it was a corrected report. What is the protocol for issuing corrected reports?"

"It's very clear. I wrote it. Any corrected report must be given to the pathologist for approval and signature."

"And do you re-review the slides on that case?"

"They are supposed to pull the slides and present it with the corrected report." Nomura frowned. "If they had done so in this case, I would have discovered the error. We could have prevented all of this."

"Well, it gets worse. I tried to retrieve the original requisition to see if the site was given as left or right breast by the submitting doctor."

"And?"

"I couldn't find it. I've had Collins and several others look through all the reqs for that entire month. Nothing."

Nomura shook his head. "Nothing surprises me about this place anymore. The filing system here is a joke. I once found a req in the rubbish can. It had fallen off the Audrey's desk. I just happened to be in the office when it happened."

"These are serious breaches of protocol. Hope I don't find anymore surprises. I'm still looking at the possibility that someone may have tampered with the report or how the report could have been duplicated for the two patients." Thompson let out a sigh. "It's painstaking but I'll get the answer."

"I know you will. Thanks. I think we need to speak to some people." Nomura knew a meeting of all parties was scheduled for 10AM the next day.

Carlisle arranged the conference between Collins, Moynihan, and the ULS attorneys, their third meeting since the lawsuit was announced. Thompson's information was disseminated prior to the meeting. They met in the ULS conference room, the ULS attorneys were on speaker phone from Raleigh, North Carolina, the ULS corporate office. Bryston also attended.

Introductions followed by perfunctory statements were made by all parties. The first 45 minutes summarized the known information. After a review of Thompson's disclosure, a recess for 10 minutes was taken. Nomura met with Moynihan in his office. "Pretty routine stuff so far. I was dismayed by Thompson's discovery but it places the burden on ULS, not you. Let me see if I can get a good angle on this."

Nomura nodded. "Let's just get this over."

"Agreed. I was speaking to the ULS counsel yesterday. They hinted that ULS is largely at fault. I know they had their information systems expert as well. Thompson knows him. He said he would be surprised if they came to any other conclusion."

The parties reconvened in the conference room. The ULS attorneys began the new round of questions.

"Dr. Nomura, we are concerned that no one has examined the possibility that you may have reviewed the same slide twice and dictated the same report."

Nomura exchanged a surprised glance with Moynihan before turning to the speaker phone. "Even if I tried, I could not dictate the same report, word for word, every punctuation the same."

"Still, it is possible?"

Nomura shook his head. "Look, DCIS is a complicated diagnosis with numerous variations and histologic patterns. There are exactly 78 words in my description. I counted it. There are commas, periods, and one semicolon. Are you telling me that I looked at the same slide, perhaps an hour or several hours later and dictated the exact same description? I'm good, but not that good."

"Who has the capability to issue a corrected report?"

"Besides the transcriptionists? Someone from information systems could, I suppose."

"What about you?"

"What are you implying?"

"Just answer the question."

Nomura's eyes narrowed as he focused on the speaker. "I, and any other pathologist, do not have the authority to make changes to an electronic report."

"I see. That's all for now."

Nomura turned to Moynihan who lifted his hand as his palm rested on the table. Carlisle rose and spoke, "Ladies and gentlemen, thank you for coming. I believe we are making progress."

Nomura turned to Moynihan. "That was unpleasant."

Moynihan nodded and motioned to Nomura to step into the empty adjacent library. "I'm not sure where they are going but I don't like it. I'll speak to them when I get back to my office. In the meantime, why don't you get me a copy of the laboratory protocol for issuing corrected reports."

"I'll have it to you by tomorrow."

Moynihan's furrowed brow came together. "I'm going to contact an expert in software programming. He worked on the original program that is similar to the one used for the LIS here. We may not need him but if ULS is going to take this direction, I'm going to bring out my heavy hitters."

"Let me talk to Carlisle and see if I can glean anything."

"Good idea. He probably won't divulge anything but it couldn't hurt."

"At the least, I think he must be realizing that there are some serious deficiencies in this department. When this is all over, I hope we can finally get the changes we need."

"I'll be in touch."

Moynihan left the library. The muffled voices of Carlisle and Collins in the next room could barely be heard over the air conditioner fan. Nomura reflected on the previous hour's conversation. Carlisle had always supported him. This incident would be a good way to turn things around. He would outline the changes that were needed and present it to him in the morning.