The Department of Pathology has been in its beautiful and efficient new space for [more then] ten months. Every day we learn more about the ways our work is improving due to the complex and well-thought-out design. That is the greatest success. As the clinical lead for the Pathology Renovation and Relocation (PRR) project, I have had the honor of helping to shape the future of Pathology at Michigan Medicine for the foreseeable future. Using Lean Facility Design techniques, the PRR project team facilitated the design and activation of 140,000 square feet of space at the North Campus Research Complex (NCRC), with all non-stat clinical laboratories, trainees, administration, and affiliated faculty and staff relocated over the summer of 2018. Along the way, the PRR team, of which I am a part, encountered many challenges and barriers, all of which were overcome through determination and a commitment to ensure the best possible outcomes for both patients and the department. This was a once-in-a-lifetime project for all of us and I think one of the things, in the midst of all of the challenges, that we tried to reinforce to people is that you will never have this opportunity again — to design space the way that is going to be best for the patients, the way it is going to be most efficient in accomplishing our jobs, and ultimately, provide the best level of care for our patients.
This was a once-in-a-lifetime project for all of us and I think one of the things, in the midst of all of the challenges, that we tried to reinforce to people is that you will never have this opportunity again —
Would the building be finished on time? Would we be able to get the specimens here in a timely manner and be able to track them along the way? Is our courier plan sufficiently robust? These and a myriad of other issues were at the forefront of our minds as we worked to ensure a successful relocation of the pathology laboratories to the NCRC. We spent significant amounts of time and energy to make it happen. In the end, we efficiently and safely coordinated the moves and we continue to have a very robust courier system and specimen tracking system.
To accomplish these goals, there were extensive communications and interactions between the PRR project team, the department, the campus, architects, contractors, designers, and others. We were in constant communication with them. We had regular meetings, informal face-to-face discussions, phone calls, and texts to ensure that all were on the same page, and to closely coordinate and prioritize mitigation strategies when issues were identified. In addition, the team worked closely with the department, laboratories, staff, administration, and faculty. Key to our success is that the labs were outstanding in this whole process, from leadership to staff, across the board. They excelled in organizing and articulating the validation timelines that they needed so that we could safely and efficiently coordinate the moves. The PRR team also worked closely with Metro Delivery (Ann Arbor, MI) to ensure the right schedule and the right kind of vehicles would be available to shuttle patient specimens between University Hospital and the new laboratories. Metro did a great job in accommodating all of our requests and needs. We had many unique requirements as a customer and they were very, very accommodating and helpful and made great suggestions to help us improve our processes.
Across the department, staff have done an exceptional job in developing workflows for packaging, transporting, and tracking specimens between UH and the NCRC. Everything is happening as smoothly as possible. Everyone has done an excellent job. The Division of Quality and Healthcare Improvement (DQHI) and Pathology Informatics (PI) played a major role in this success with the development of the PathTrack asset tracking system. This critical system enables us to know where specimens are during each point in our processes.
However, there still are challenges that have not yet been resolved. The things that have persisted are issues related to the building, and that has been a little frustrating. We are still working our way through some unanticipated issues—including adjustments and enhancements to heating and cooling as well as appropriate air-balancing and airflow. These issues were my greatest surprise in the project. The PRR Team worked hard to have success over the parts of the project for which we had direct control, but other aspects were more challenging. As it turns out, the coordination during design between the architects and engineers was not as strong as we were led to believe. This ended up causing rework and challenges during move in, some of which persist today. This was not something we anticipated or predicted, and presented a lesson the PRR team learned as we begin to tackle the next phase of the project – the UH renovation for the core labs.
Communicate often and broadly. The key takeaway from this project is that you cannot over-communicate. People hear and interpret messages in various ways. People handle change differently and as such, the messages that go out need to take different approaches to adapt to different audiences. This was a major change that had significant cultural impacts on the department. We expected that there would be an impact to our culture, but it was much more significant than we anticipated. We are working to learn from this and take that lesson into the renovation of UH, and address some of these cultural issues through communication. There is a concept from Taiichi Ohno, the father of the Toyota Production System, that states, “Having no problems is the biggest problem of all.” When “everything is fine” and remains “fine” throughout the planning process, that is an indicator that a group may not be digging deep enough and that more proactive communication is needed. Some groups are a little shyer or hesitant to share or to talk about how things are not working. So we need to be proactive in having those conversations and making sure that everyone is moving in the right direction.
The key takeaway from this project is that you cannot over-communicate.
As the UH renovation project moves forward, communication will be key to better understand challenges, to build better relationships, and to increase awareness, so that the team is not making any assumptions. That is a challenge, but also a tremendous opportunity. I appreciate the trust that the department put into me in allowing me to be in this position to help. I am proud of what we have been able to accomplish.
The newly-renovated workspace at NCRC afforded the opportunity for the department to purchase original artwork, supporting local artists. Working with Joy Naylor and Diane Bennett of Ann Arbor-based Distinct Design and U-M Interior Designer, Kate Stahl, an artwork committee chose pieces inspired by nature to complement the complex’s park-like setting.
The artists include: Francesc Burgos, Lynda Cole, Carlye Crisler, Connie Cronenwett, Kim Ensch, Karen Ehart, Helen Gotlib, Janet Kelman, Jennifer Martin, Susan Morosky, Eric Nye, Middy Potter, Elizabeth Schwartz, Jill Stefani Wagner, and Karin Wagner-Coron.
Among the artists are Art Prize winners, including Lynda Cole, whose work in oil pigment stick, cold wax, and encaustic are featured outside the chair’s office and the Division of Quality and Health Improvement. Cole, along with several other of our featured artists, is a co-owner of the WSG Gallery on Main Street in downtown Ann Arbor.
Artist, Connie Cronenwett says that she feels most like herself while she is painting and that the process gives her the opportunity to really observe. “It’s like you lose a certain part of your ego that just takes a walk and you’re so engaged with that process and it’s very challenging and it’s freeing at the same time.”
Artwork on display serves as a daily inspiration for all those who work in its midst and has inspired at least one NCRC tenant to become an artist himself, as Duane Newton has taken up watercolor lessons.
Jill Stefani Wagner uses her work as a way to document her community. ” I like to capture what life is like now. Not idealized. I always put the telephone poles and everything in because I want it to be a record,” she says. She adds that the support she has had from hospitals purchasing her art has been much appreciated and it’s a way of keeping art alive, especially after the residential market basically disappeared back in 2008. Most of the artists featured in the new space are from Ann Arbor and all are from the Midwest.
WSG Gallery | 306 S. Main Street, Ann Arbor, MI 48104 | Webpage
A flurry of last-minute preparations and problem solving consumed much of 2018 as the Pathology Renovation and Relocation team and strategic move captains prepared for the relocation of faculty, staff, trainees, and all the implements of a modern clinical pathology facility to the North Campus Research Complex. Throughout, the move captains ensured their laboratories, faculty neighborhood groupings, trainees, and administrative staff transitioned smoothly to Pathology’s new home 2.8 miles from the University Hospital. Over a period of approximately 3 months, these teams converged from locations across Ann Arbor into a consolidated 140,000 sq. feet state-of-the-art space designed for collaboration and to embrace the future. For the past year, the teams have been adjusting to the new space, adapting to new workflows, and taking advantage of the opportunities presented.
The first thing many noticed about the new space is the natural light! Instead of being in basements or in crowded, internal laboratories without any windows, the laboratories have floor-to-ceiling walls of windows looking out at the park-like setting of the North Campus Research Complex. The space is bright and inviting. The laboratory bench space is designed to be movable, so it can be easily reconfigured as future technologies require new workflows. The labs are equipped with many familiar pieces of equipment, but also many newly-acquired pieces to enhance the capacity of the labs. Each laboratory was carefully planned using Lean Facility Design for optimal workflows and to encourage mentor/trainee interactions and teaching. In addition, the nerve centers for each lab are housed within the laboratories with clear line-of-sight between managers and the bench staff.
Larger-than-life patient stories posted on walls in both laboratories and hallways remind all that excellent patient care is the focus of our work. Hallways and common spaces are enhanced with locally-created artwork. Conference rooms with glass walls line the exterior walls across from glass-walled offices, ensuring both offices and conference rooms are cheerfully lit. While not all offices are along this corridor, the majority are just steps away from natural light. Small offices make room for many common areas, conference rooms, and other work spaces to encourage collaboration among faculty and to enhance communication between faculty, trainees, and staff. A favorite common area to all is Central Park, complete with a long plank-wood dining table in a kitchenette adjoining high tables, soft seating, and a long fireplace, with natural greenery and artwork. This warm and welcoming space is shared by all of Pathology and is the heart of the new facility.
ADJUSTING TO CHANGE
The beautiful facilities provide the framework for success, yet they also require staff to adapt to the new environments. In the molecular pathology division, six laboratories that were scattered across Ann Arbor, each with separate cultures and norms, are now co-located in contiguous molecular laboratories. The new space provides an opportunity to have back-up equipment available in case of equipment failure. “The move is a win for the Molecular Division,” stated Dr. Thomas Giordano, Director of the Division of Molecular Pathology. “We were in Traverwood (an off-site facility),” stated Dr. Lina Shao, Director of Cytogenetics, “which was isolating. Now we are at the NCRC and are more fully integrated. We feel like we are a real part of the Department. The move had a positive impact for our lab.”
The anatomic pathology laboratories now require patient specimens be transported between the UH and NCRC. This created an entirely new workflow, requiring additional staff, and a complex specimen tracking process. Pathology Informatics and the Division of Quality and Healthcare Improvement elegantly solved the tracking challenges with PathTrack™, which was featured in last year’s edition of Inside Pathology Magazine. “When we first moved in, PathTrack wasn’t able to keep up with the increased demand, so the application did not work efficiently as the number of users increased,” explained Dr. Ul Balis, Director of Pathology Informatics. “So the team stepped up, not only solving that architectural problem, but also extending certain features. Now we are deploying PathTrack to multiple clinical sites at the University Hospital and the Taubman clinic.” PathTrack has attracted significant attention from other organizations as well.
Administrative staff are located in close proximity to the faculty providing more opportunities for interaction and discussion, improved communication and engagement.
With the more open and collaborative environments, faculty and staff also faced adjustments. Administrative staff are located in close proximity to the faculty providing more opportunities for interaction and discussion, improved communication and engagement. Faculty are now part of multi-disciplinary neighborhoods, which has led to opportunities to reach out to neighbors for quick case conferences or for impromptu meetings at multi-headed microscopes. Residents and fellows are located in bright, modern space at the heart of the laboratories, adjacent to the sign-out areas and near the faculty suite. Robust educational experiences were built into the layout of the laboratories and sign out areas. While the overall environment for our trainees significantly improved, the relocation also meant that the residents and fellows needed to commute between the hospital and the laboratories for rotations in the stat labs and to attend some seminars and multi-disciplinary conferences. Digital signage prominently displayed throughout the space includes both inbound and outbound bus arrival times to assist in this commute. Pathology Informatics is located just down the hall from the faculty suite and administrative offices, which enhances service delivery and access for technical support. “Having MLabs right here with us makes it much easier to reach out to the outreach team themselves,” said Dr. David McClintock, Associate Professor of Pathology Informatics and Assistant CIO for Michigan Medicine. “We are close to the billing team and both AP and CP operations as well as Administration,” added Kathy Davis, Administrative Director of Pathology Informatics.
BUILDING ON SUCCESS
Now that we have been at the NCRC for one year, people are settling into their new space and routines and are beginning to look to how they can take full advantage of our facilities.
“The molecular laboratories have come together and the changes we have seen with the molecular lab and our work are significant,” stated Dr. Shao. “In cytogenetics, we were manually extracting DNA. The molecular lab, however, uses robots to do DNA extractions. Now we are able to use their resources. We validated DNA extraction by robots for both blood and bone marrow. That saves us a lot of work.” In addition, the new microarray laboratory layout allowed for other efficiencies. Rather than being in rooms on opposite ends of the hallway, the pre-PCR and post-PCR rooms are now in adjacent air-pressure-controlled environments to reduce contamination possibilities. Technologists simply move specimens a few steps rather than boxing them up and walking down the hall. Use of a new Thermotron eliminated the need for a cold room to process specimens, reducing exposure to caustic chemicals. Specimens are now safely processed in the contained, vented, box-like Thermotron.
“Now that we have the move done,” stated Dr. McClintock, “we are starting to work on new projects. We have some very good potential pathology solutions in the pipeline that this lab has enabled us to do. We have new, dedicated space for development for the future.” “This new space allowed us to be more productive with the precision medicine project,” agreed Dr. Balis. “One example of this is the whole slide-viewer technology developed by Dr. Jerome Chang, which has become the national standard now for the NCI/NIDDK for viewing whole slide images. That was a huge win!”
As Pathology continues to integrate within the new space and adjust to new possibilities, a new project has been initiated – the renovation of the STAT and core laboratories at the University Hospital. This four-year project will continue to both challenge us and help us improve patient care as we look to the future. The PRR team learned a great deal from the relocation of our laboratories to the NCRC. Many of these lessons learned are being applied to the University Hospital Project. We are looking forward to the possibilities for enhanced patient care that will emerge as a result of these renovations.
It began with a vision. Dr. Riccardo Valdez, Director of Clinical Pathology, was interested in moving the Clinical Flow Cytometry lab from University Hospital (UH) to the HLA laboratory at the North Campus Research Complex. The shift would allow for putting similar technologies, like HLA flow and crossmatch and hemepath flow, together. It would also move the laboratory to where cases are signed out and to where marrow aspirates are stained, differentiated, and signed out.
The move was first proposed in the fall of 2018 and deemed possible. Then, the hematopathology team, led by Usha Kota and Julie Bensinger; the HLA team, led by Abdulkadir Abdulle; Clinical Pathology Operations Director, Kristina Martin; and the Pathology Relocation and Renovation (PRR) team went to work in planning for and implementing the move.
Multiple lean process flow sessions were held to evaluate the best layout for both the HLA teams and Flow team with all groups making changes, developing compromises, and working together for the best overall solution. “Once the layout was set, numerous facilities teams needed to work together to make the change happen. This even involved one week where significant electrical and mechanical work was done in parallel to the on-going HLA lab work,” says Christine Baker, PRR Project Manager.
The teams also worked with PRR to identify storage solutions. To fit Flow Cytometry into space formerly occupied by only HLA, both teams needed to develop more lean approaches to storage and supply management.
As part of the move, the Flow Cytometry lab worked with the Blood Bank to hand off STAT stem cell testing that could not be moved to NCRC. “The Cell Therapy team within the Blood Bank had to take on a new testing paradigm for them,” explains Baker. This involved instrumentation that was new to them and new testing protocols to learn. The team did this while short-staffed and managing their own workload. The Flow Cytometry lab validated instruments and trained the Blood Bank staff on testing, trained personnel from marrows and HLA to work in hemepath flow, and trained personnel from HLA to assist with marrows receiving and staining slides. Flow Cytometry senior staff worked with vendors to assist with instrument moves, installation, and inspection, and performed validations in HLA and Flow with the data approved by section directors.
The result? A phased move that began in April, brought specimens to NCRC beginning May 14, and was completed in late May. The teams are still working with PRR on the transport of cases to sign out, both from University Hospital to NCRC and within the NCRC complex itself, but the bright, open space in the new combined HLA and Flow Cytometry lab is better-configured for the workflow than UH where the team worked in segmented, smaller spaces. Meetings with the Flow Cytometry director are now easier, as everyone is now in one building. This is improving work life for faculty who now have better access to the laboratory and for staff, who have access to better schedules and to better parking options.
An additional benefit is that when the technologist for marrows is unavailable due to a vacation or sick day, Flow Cytometry personnel are now trained to cover. The team is continuing to work on cross-training in both HLA and Flow to improve turn-around times and even out the workload, and working to reduce redundant work in order to address increased workload without adding full-time employees. This project is another exciting example of lean design and the ways the new space at NCRC is having a positive impact on faculty, staff, and patients alike.
Today brings another edition of DOP Updates, an email sent to members of our Department of Pathology team and interested stakeholders intended to share information of common interest. As per usual today’s edition is also [linked] in PDF form to preserve formatting across your mobile platforms. Send me a note if you have comments, concerns or stories to share with me or in the next edition of Updates.
In the last August 2018 edition of Updates, I talked about NCRC, what was working, what improvement opportunities remained, and some specific strategies to bridge the gaps that separated us from where we wanted to be. Today, with the support of our department and the institution we have made substantial progress while recognizing that much work remains to be done.
Those doing the work are the frontline of our quality program, a program in which we do the work in a standard way that we created, remain alert to things going wrong, fix it when it does, and find and fix the root cause(s) so that it is less likely to happen again. In our case staff, trainees and faculty have been at the frontlines, helping us recover and stabilize from a move that included well-designed solutions working exactly as intended and other well-intended plans that served only to show us what we could not have otherwise known. Focusing on our problems as learning opportunities we are responding with collaborative countermeasures that, in the spirit of Plan-Do-Check-Adjust (PDCA), will serve as the next round of experiments from which we will learn more about our work in a new place with a new set of realities, opportunities, and challenges.
While those at the front lines are making adjustments in collaboration with managers and laboratory directors to improve the quality of our work, we have launched a large cross-functional project team working on the value stream from arrival at N-LNC to archiving or return of materials with the goal of more efficient, timely and safe receipt, transportation, delivery and archiving of patient assets relevant to the daily care of those who look to us for answers, care and compassion. At the moment we have become the rate limiting step to care in several of our practices which is a place in which we have never been before, and we are passionately committed to close the gap between where we stand today and where we need to be to remain the place that others imagine when it comes to excellence in delivery of laboratory services.
In other areas, there are experiments underway to understand the link between our new and soon-to-be remodeled spaces and our capacity for collaboration and creativity. One experiment includes a daily huddle held every Thursday morning at 8:30 AM in “central park” in building 36 at NCRC focusing on learning from one another and being more intentional about using the space as a tool to make us better than what we could have otherwise been. Last week we touched on gratitude and the things that matter most as a conversation in response to concerns expressed about the risk of burnout for our staff, our trainees and our faculty. While we tend to focus on workload (“overburden”) when we speak of burnout there are multiple important drivers that include,
Feeling and expressing gratitude with one another as a daily practice while focusing on the things that matter most may address, at least in part, some of our needs when it comes to community, social support, and an understanding of values that are either aligned or for which there are gaps that might benefit from our attention. In our conversation about the things that matter most to those who were gathered in that space we heard about always putting patients and families first which may sometimes mean going above and beyond (“going the extra mile”) our usual expectations. We talked about the importance of being recognized for one’s work and doing what needs doing because it matters. That was linked to the importance of feeling valued and supported, having opportunities to grow both personally and professionally, having opportunities to meaningfully participate in cutting-edge health care, transparency in all things including the decision making processes that affect our daily work lives and being resourced appropriately to position all of us for success. We concluded by talking about the relationships between our values, feeling supported, and resources. And while it may be easy to point fingers in any conversation about resources in a resource-constrained environment, we recognized that all involved are moving forward with the best of intentions but too often without successfully stepping into the shoes of one another to better understand the resource allocation paradigm. And we began to wonder what experiments we might run to close the communication gap in the spirit of improved relationships, understanding and transparency with the goal of being more effective partners with those in leadership roles whose decisions we may not always understand. Stay tuned as we continue the work of closing some of the gaps that may contribute to the sense of burnout percolating through our department.
Values ↔ Support ↔ Resources
In the meantime, I have [linked] a recent publication that focuses primarily on physicians when it comes to the national phenomenon of burnout in our provider community. The principles apply more broadly to all of us. Please send me a note if you have your own thoughts about experiments we might run in order to better understand the problem and in better understanding the problem create solutions that might pave the way to a healthier future.
Last Thursday night I received a text from my brother who lives – or lived – in Paradise, California, a town largely destroyed by the Camp Fire still burning in northern California. He sent it so that his family would know that he and his wife had safely evacuated their home. He smelled smoke and heard about the evacuation order while driving to his place of business in Chico. He turned around to rescue his wife. By the time he arrived, it was clear that they were in trouble – the picture to the left was taken from his backyard. They ran to their car and escaped down a road threatened by fire on both sides. They would learn later that all 4 of the earliest reports of people who perished in their cars were discovered the road on which they live(d). It was close.
In response to the protestations of concern and grief from others, he responded with gratitude. Happy to be alive, happy that his wife was safe, grateful that the only things they lost – including not only their home but also her Paradise store – could be rebuilt and replaced, and grateful for the friends that offered them shelter.
For years he labored on creating the perfect man cave in a caboose carefully positioned on a segment of track constructed on a roadbed that he himself built. When he sent the picture of what remained of his caboose and the melted lamps adorning the yard around them I responded by saying, “A memorial to the place!” He replied, “Actually a project still in place.”
Last night he texted another picture with the caption, “It’s good to be homeless.” In the phone call that followed he reiterated the same, saying that compared to the suffering of others this was but a minor inconvenience that reminded him of the things that matter most.
This morning as I was writing this story, I received an email from a grateful patient dying of his widely disseminated cancer. He wanted to share with me the importance of the comfort he can offer to others in the midst of their grief, and he wanted to tell me about acceptance as a strategy for navigating this latest and perhaps last chapter in his life journey.
Never once have I walked out gratitude in a way that comes anywhere close to the courage and gratitude modeled with sincerity and grace by my brother and a patient who has taught me far more about life than I was able to teach him about his cancer. Daily I complain and worry about minor problems that pale in comparison and have little connection to the things that matter most. It is a reminder to me and perhaps to you the importance of gratitude, grace, kindness, and courage in the face of adversity, and that what matters most is not so much what happens to us but how we respond. Arianna Huffington said it this way:
“We have little power to choose what happens, but we have complete power over how we respond.”
That’s the news to the moment from my desktop at NCRC. Please send me a note if you have something that you would like to share with your teammates. Until the next time, let’s be careful out there . . .
By Jeffrey Myers, MD | 22 August | Department of Pathology Updates, Vol 4 (1)
Welcome to the latest edition of DOP Updates, a periodic email sent to members of our Department of Pathology (DOP) and other stakeholders to share information of common interest. Updates are also [linked] as a PDF file to preserve format across your mobile devices. Please send me a note if you have something that you would like to share regarding this or any future editions of Updates.
You did it!! In various ways each and every one of you participated in one of the most significant shifts in the history of our department – you executed the relocation half of our PRR (Pathology Relocation and Renovation) project. To the numerous staff, trainees and faculty who worked hard to make it a reality we owe a debt of gratitude. To one another we owe civility, compassion, and kindness as together we struggle to right the things that went wrong and return to a place of stability in which our focus, as always, can remain first and foremost on those who we are privileged to serve.
Already we are beginning to see some of the possibilities created at NCRC, measured not so much in terms of rewired workflows and logistics but instead by human interactions. We have, all of us, emigrated from geographically distributed care teams for whom parochial interests framed disparate and customized workflows and cultures. What worked in one place was done differently in another to the satisfaction of all participants. With our co-location of much of our clinical operations, we have new opportunities to re-think the power of standard work while also acknowledging the cost to individual prerogatives and the very human desire to preserve the standalone solutions long familiar to us.
We have also been reminded that change is hard. Robin Sharma reminds us that, “All change is hard at first, messy in the middle and gorgeous at the end.” Change of the magnitude endured over the last 8 weeks comes with its own unique set of challenges that in some cases was compounded by a near perfect storm seemingly determined to sink us at a time when we were already vulnerable. In histology, for example, days before our move we suffered the unanticipated loss of three highly productive histotechnologists to a combination of resignations and injuries sustained in a motor vehicle accident. This compounded existing shortfalls in staffing to which we were already recruiting. Combined with brand new models for specimen transport and revised workflows, the work slowed down. As communicated in previous emails our managers and supervisors responded with innovative plans to overcome the mismatch between demand and capacity, including mandatory overtime, weekend shifts, and realignment of patient care duties to better match our resources with those pain points most responsible for slowed delivery. Our managers, supervisors, and staff have been working elbow-to-elbow to do the work in a way that chisels away a backlog triggered less by our move and more by an unanticipated reduction in capacity. Rectifying this mismatch has been a topic of daily discussion at our administrative huddles to stay abreast of the challenges and tap into the collective wisdom of those gathered to focus on enterprise-wide challenges and countermeasures.
In addition to challenges in getting the work done, we have learned that some of the logical and valid assumptions about how cases and slides would from our laboratories and libraries to the places in which they are translated into diagnoses and reports has not gone as well as we had hoped. This does not reflect a failure to plan but rather the discovery that the plans we made, however thoughtfully developed, did not function as predicted. This is the power of P-D-C-A: planning is important but the plans themselves often serve only as vehicles from which to learn what we could not have otherwise known. In the absence of more robust solutions many of our work areas and neighborhoods have very understandably reverted to legacy models for transporting and archiving cases, models that made sense in a geographically dispersed practice but may make less sense as we learn to work more effectively in a place intended to leverage the unique opportunities that accrue from being together.
In our molecular laboratories, we are learning that moving in together creates opportunity but also brings the sorts of challenges inevitable when someone we like becomes the person who greets us each morning and says goodbye to us each day. It is the right thing to do but adjusting to the change more closely resembles a journey than it does a destination. As we courageously embrace uncomfortable opportunities unique to this place we are building and nurturing a culture of collaboration and innovation that positions us for success in delivering on the expectations appropriate for an industry leader in the molecular tools fundamental to the future of precision medicine.
And while challenges remain, by earlier this week we began to turn the corner on some key dissatisfiers affecting our staff, our trainees, our faculty, our providers, and most importantly our patients. We are transitioning from “hard” to “messy” with occasional glimpses of “gorgeous” if you tilt your head just right and imagine what’s possible.
For example strategies and tactics implemented by our managers and supervisors are paying off in histology. As of yesterday, our histology lab was back on track, cutting and delivering the work on a schedule that more closely resembled what previously served as our current state, and they are maintaining those gains through today. By aggressively recruiting in an area for which there is a thin and highly competitive applicant pool, at least one new candidate has agreed to relocate to Ann Arbor. With institutional support, we continue to fill open positions in the short term while opening conversations about long-term strategies such as Michigan Medicine-based educational programs in allied health fields to more confidently build the people talent required to sustain our future.
Earlier this week Corrie Pennington-Block, Scott Owens and I met to talk about the scope of a project to tend to unanticipated gaps in delivery and archiving of cases and related assets. Today an email went out to medical leaders and managers inviting nominees to participate in a project that has as its primary goal to address shortfalls in timely delivery, sign out, and archiving of cases. This project piggybacks onto already GREAT work being done by our slide delivery team and our AP Laboratory Operations group, recognizing that the scope of this opportunity is bigger than any single division and will require focused collaborative work that crosses clinical and administrative units. Stay tuned for further updates as we work to first understand and then mitigate gaps in our ability to deliver on service level expectations.
Civility as an expectation and a strategy
Don Berwick, a luminary and opinion maker when it comes to quality and safety in medicine, described in his 2015 IHI keynote address the importance of civility as a tactic for transitioning medicine from what he characterized as Era 2 to Era 3. If you can find the time it is worth the 52.5 minutes required to hear his entire speech at HERE. But if you have only 1.5 minutes to spare, jump to the 35:15 mark of his talk. He quotes long-time Board Chair of IHI and former Board Chair of the Mayo Clinic Foundation, Dr. Bob Waller, who said, “Everything possible begins in civility.” Dr. Berwick goes on to say that in Era 2, which is the era in which we now find ourselves, “civility, and therefore possibility, have been in much too short supply” concluding that “healthcare needs the decorum not of a boxing ring but of a dinner table.”
In these times of change and stress, how we treated and cared for one another will be remembered far longer than the time it took to get a case, our transportation failures, and the transparency of our walls. And how we treated one another will color how we are perceived by others including those who look to us for comfort and hope. We will bridge the gap from messy to gorgeous at NCRC. And that bridge will rest on a foundation of civility and a common commitment to the things that matter most when it comes to the rewards realized from working together to create the future of our discipline.
That’s the news to the moment. Please send me a note if you have comments or would like to share something in the next edition of DOP Updates. In the meantime, let’s be careful out there . . .
By Kara Gavin | 27 June | Michigan Headlines
A new facility opened this week at the University of Michigan will touch the lives of nearly every person treated at U-M clinics and hospitals, and patients across the state and nation. Called the Michigan Medicine Clinical Pathology facility, it will improve how patients and doctors get vital information from samples of patients’ cells, tissues, blood, urine, saliva and DNA.
The state-of-the-art location will allow thousands of doctors to diagnose or track their patients’ diseases, plan their treatment and see how they’re responding to care.
Millions of patient samples will arrive at the new location each year, to be tested by teams of highly-trained staff using advanced equipment, then examined by specialized U-M physicians called pathologists who can provide an expert diagnosis.
Built as part of a $160 million project, the 139,000-square-foot facility will make it possible for U-M’s Department of Pathology to serve the ever-growing demand for advanced clinical and anatomic pathology testing. Some of the tests U-M offers are available from few other places in the country.
That demand has risen nearly eight percent every year for the last decade. And nearly 10 percent of the demand comes from outside U-M, from hospitals that send samples hundreds of miles for advanced testing through the MLabs service.
First patient sample arrives
India Stone uses PathTrack to scan the first specimen received in our new laboratory space.This week, the first patient sample tested at the new facility traveled just 2.6 miles, from U-M’s main University Hospital to a dedicated entrance at the North Campus Research Complex.
A new digital tracking system kept an eye on the sample’s progress from the time the sample was obtained through testing, registered the pathologist’s expert diagnosis, and then shared the results with the health team that ordered the test. Michigan Medicine patients can access their own lab test results, and doctors’ notes about them, via an online portal and mobile app.
“This new Clinical Pathology facility will allow us to keep pace with the rapidly accelerating growth in sophisticated analysis of patient samples, improving efficiency and turnaround time while providing more than 1,100 different test options for the providers who rely on us,” says Charles Parkos, M.D., Ph.D., chair of the Department of Pathology. “This is the most up-to-date pathology facility in the country.”
Designed for lean operations
Spacious laboratories with natural lighting bring similar tests together under one roof, increasing efficiency and building in redundancies in case of equipment failure.The project to create the new clinical pathology facility started more than four years ago with a nearly-blank slate: four vacant and connected buildings in northeast Ann Arbor originally built for pharmaceutical research. All were part of U-M’s 2009 purchase of a research complex formerly owned by Pfizer, Inc. Some of the buildings had just been constructed when Pfizer sold them.
Most of the 30 buildings at NCRC now house U-M research laboratories and other operations. The new project, in the southern portion of the site, represents the first permanent use of NCRC facilities for clinical care operations.
Converting the empty buildings for clinical use, and preparing to move many clinical operations out of the main U-M medical campus with no interruption to patient care, took years of careful planning. The project also includes renovation of Pathology space at University Hospital to create a faster and more modern facility for rapid testing that guides the care of hospitalized patients.
Throughout the process, staff and faculty used the “lean thinking” approach pioneered by the auto industry to design their new space with architects, engineers, designers and vendors. They sought to bring together testing operations, administrative functions and educational programs that were previously spread out among 10 separate locations across the medical campus and the city.
"Central Park" is the largest of many collaborative spaces designed to inspire process improvements.For each type of test Pathology offers, the team created the ideal layout for sample handling, testing equipment, clinical consultation space, and educational space for faculty to train the next generation of pathologists through U-M’s top-ranked residency and fellowship training programs.
Each type of test has its own dedicated area, with many new pieces of technology purchased for the new site. In some cases, the process that staff had to follow in their old location required them to walk hundreds of steps. With the lean-designed facility, that will be cut to dozens of steps.
Many pathology specialties in one place
Bringing many functions together in one place will improve efficiency and speed – but also improve patient care. For instance, Parkos says, when a cancer patient has surgery to remove a tumor, pieces of the cancerous tissue are brought to the Surgical Pathology area to be preserved, finely sliced, stained and placed on microscope slides for pathologists to examine.
Previously, if the pathologists wanted to seek the input of other specialists, they often had to walk as far as half a mile to get another opinion. Now, they can walk into the next room and ask, making for more efficient, timely and accurate care.
Another major feature of the new facility is in the Microbiology area, where teams process samples from patients with suspected infectious diseases ranging from the mundane to the exotic. A new 40-foot-long automated BD Kiestra system will help staff reduce the time to diagnosis by five to ten hours – saving critical time for patients seeking the most effective care for the infection that’s causing their symptoms, and for those seeking to prevent further spread to others.
Other improvements abound. A new electron microscopy lab will improve the speed for detailed examination of fine structures inside patients’ kidneys, for instance. Six molecular diagnostic laboratories have been co-located, enabling cross-coverage and equipment redundancy. This will enable faster genetic testing to look for mutations in DNA that may be causing a patient’s disease.
All of this, Parkos notes, positions Michigan Medicine well for the era of precision health, where an individual patient’s care can be designed based on his or her unique characteristics down to the level of DNA variations. The facility will also be able to offer new tests emerging from U-M research.
For more about the project see http://michmed.org/E1jwx
For more about Precision Health at U-M, see https://precisionhealth.umich.edu/
An article in the June edition of CAP Today outlines the transformation that the Department of Pathology has undergone via lean facility design in its move to the North Campus Research Complex. Through interviews with Department Chair, Charles A. Parkos, MD, PhD as well as Pathology Relocation and Renovation Project Manager, Christine Baker, and other leaders, you’ll learn how the process involved engaging faculty and staff to discover the best workflows for specimens, people, and materials, leading to improvements in patient care. Read the full story.
By Jeffrey Myers, MD | 6 April | Department of Pathology Update Vol. 3.5
Today brings another edition of DOP Updates, an email sent to members of our Department of Pathology (DOP) team and interested stakeholders to keep you abreast of issues of common interest. Updates are also [linked] as a PDF file to preserve formatting across whatever mobile devices you are using to read it. Please send me a note if you have something to include next time.
Aerial Shot of the North Campus Research Center (NCRC).Today marks 58 days until our first patient specimens make their way to the North Campus Research Center (NCRC) as the first phase of our Pathology Relocation and Renovation (PRR) becomes a reality. This is a journey that began over 4 years ago when we were confronted with the opportunity to co-locate clinical operations, staff and faculty in a place challenged by its distance from the home to which we have become accustomed for over 30 years!
From the beginning, there was understandable and valid skepticism about the wisdom of such a move. And despite whatever your personal skepticism all of you have worked hard to sustain our commitment to delivering world-class care from a shifted paradigm that was hard to imagine in our earliest days. With the help of Christine Baker, Duane Newton, PhD and their remarkable Lean design and implementation teams we learned the power of harnessing the experience and creativity of those who do the work to design and build our future, a future designed with the flexibility to respond to the rapidly changing landscape of laboratory medicine in particular and academic medicine in general.
This is an exciting and intimidating moment in our history that stands to change the way we care for our patients and one another in very substantial ways. The work that you have done to get us here will stand as a durable tribute to our determination to do better tomorrow what we already do well today, not because it was easy but because it was hard. Celebrating victories that come at no cost is the stuff of everyday politics; creating unique value in a place from which critics said no value could emerge is altogether different and the sort of breakthrough worthy of celebration by those who discern the things that distinguish great from the merely good. And as we are reminded from time to time, achieving these sorts of breakthroughs rests not on the shoulders of individuals but on the shoulders of the team, the team, the team!
As we find our way to the rapidly approaching finish line, it is critically important that all of us – frontline staff, administrative support, technical leads and supervisors, managers, medical directors, trainees, students, and faculty – remain focused on our purpose which is to transform the experiences of our patients, their families, their providers and one another in ways that delight and surprise them and us. There is no doubt that much of what we’ve planned will prove wrong while also serving as the learning opportunities essential for getting it right in the spirit of P-D-C-A. We will discover unanticipated challenges that will require innovative responses while also learning the power of working together in an environment that celebrates collaboration and creativity.
Should you ultimately decide that this is not the place for you we will understand, but wait until we get there to pass judgment. The truth is you cannot know unless and until you walk the walk. Between now and then we ask that all keep their eyes on the collective prize that has been years in the making. This is your time . . . make the most of it!
On December 13, 2017, we had our first discovery meeting to understand the challenge of bringing on our MidMichigan Health (MIDM) patients and colleagues, including all of their affiliated hospitals, as a reference laboratory client. Our purpose was to do what had never been done in so short a time – to build functional orders and reporting interface, an online handbook, and the infrastructure and workflows that would allow us to serve their reference laboratory need going forward. . . . and to do that in a little more than 3 months! By way of comparison, the time required to do this work is traditionally more like 6-12 months. Responding to this opportunity while also doing the work required for our move to NCRC seemed nearly an impossible task, and yet on March 27, 2018, at 07:00 we went live as the reference laboratory provider for MIDM!
As is always true in a project intended to deliver a “minimum viable product (MVP)” that safeguards the interests of our patients at launch while serving as the platform from which to learn and grow, we have learned an enormous amount since our go-live date. Our teams are working hard to rapidly implement countermeasures while memorializing lessons learned. The information captured both before and since go-live by Julia Dahl, MD and her cross-functional, multidisciplinary team will allow us to not only continuously improve the services provided to MIDM but also to replicate the work in a more sustainable and scalable fashion as Michigan Medicine continues to expand our integrated network to sustain our viability as an academic health care system going forward.
And as with NCRC and PRR, our collective success in doing this is necessarily the work of the team, the team, the team! In this case, the team includes not only those who dedicated weekdays, weekends, mornings, afternoons and evenings to building it but also to the staff and faculty who have responded with hard work and creative ideas since going live on March 27th. THANK YOU to the countless individuals who together account for this remarkable success story!! There can be no better example of what it means to reap the reward realized from working together to accomplish what others predicted was impossible – that truly is the Michigan Difference!
Civil rights members pointing in direction of the assailant who shot Martin Luther King Jr. / Photo: Joseph Louw/The LIFE Images Collection/Getty Images.On Wednesday we paused to remember April 4, 1968, the day on which Martin Luther King, Jr. was assassinated by James Earl Ray as he stood on a balcony at the Lorraine Hotel in Memphis, TN just after 6 pm as he prepared to join friends and supporters for dinner.
I was 13, living a privileged life in Sioux Falls, SD, a place well removed from the racial tension of Memphis. I remember the moment as news-worthy rather than something that touched my life or heart as it did those suffering the consequences of racism and hate. On Wednesday StoryCorps pinged my email box with a message to commemorate the anniversary. The text read, “On the 50th anniversary of the assassination of Dr. Martin Luther King, Jr., we remember his legacy as told by StoryCorps participants.”
“Participants” included Dion Diamond who at 15 began his own non-violent protest of private “sit-ins” in response to a lifetime of “whites only” signs in Arlington, Virginia. With the unimaginable courage of the sort that seems less common today, he modeled the strategies of Martin Luther King, Jr by sitting where he wasn’t welcome to spark the dialogue that would eventually change the law, even if not the culture. At 76 he looks back and acknowledges that his grandchildren may not be, “the least bit interested” but he remains proud that in the book of world history, “a period or a comma in that book is my contribution.” His experience challenges us to remember that, “The good you do today will be forgotten tomorrow. Do good anyway.” (Kent Keith. The Paradoxical Commandments)
“Participants” included Lawrence Cumberbatch who shares with his son Simeon what it was like to walk for 13 days to make his way from New York City to Washington, DC to bear witness to Dr. Martin Luther King, Jr’s “I Have a Dream” speech. He tells about being marched for 30 miles through the state of Delaware with state troopers in front and behind to make sure that they did not stop for any reason. When asked what he thought about the speech he responded that, “‘Nobody who was on that podium was thinking about the speech.’ It was just mind-blowing to look at this sea of people. You’ll never see this again.” More than 50 years later, Dr. King’s dream remains just out of reach as we continue to judge others not by the content of their character but by the color of their skin, the place that they call home, their place in the hierarchy of socioeconomic class, or any other differences that set them apart from those with whom we’ve grown comfortable. For Simeon, his father’s march made him, “a hero of mine.”
Listen to Martin Luther King, Jr's last Sermon.And the participants included Bessie and Taylor Rogers who on April 3, 1968, were in the Mason Temple in Memphis when Martin Luther King, Jr. declared that he had been to the mountaintop from which he could see the promised land. In a message that was eerily prophetic, he assured those in attendance that they would get there even if he himself might not get there with them. He comforted them that he was, “happy, tonight. I’m not worried about anything. I’m not fearing any man.” It was his last speech. For Taylor, it was, “kinda like you lost a part of your family. You really can’t describe it. He stopped everything, put everything aside to come to Memphis to see about the people on the bottom of the ladder, the sanitation workers.”
Anniversaries of this sort are cause for nostalgia and reflection. But until nostalgia and reflection translate into real change the promised land for many remains a cruel dream. Those like me who are insulated from the reality of persistent discrimination and hate might easily conclude that the world is a better place compared to 50 years ago. And perhaps in some ways it is. But in many other ways, we continue to avoid the work that will take us to that place in which we are each of us judged not for our differences and our weaknesses and failures but for the victories to which every human being can lay claim as a precious and once-in-a-lifetime inhabitant of this place.
It starts here. Never underestimate your own capacity to change the world. Start with the ways in which you treat one another, and especially the way we treat those who look to us for comfort when confronted with disease and discomfort. It starts with you.
That’s the news to the moment. Send me an email if you have something that you would like to share with others. Until the next time, let’s be careful out there . . .
Lady Blue by Cel aromin Gallardo, Hematology. Acrylic on canvas.Our new space at the North Campus Research Complex includes many opportunities for incorporating artwork. Three art gallery spaces have been designated for rotating art exhibits and it's been determined that the inaugural exhibit in these galleries will feature artwork created by those in the Department of Pathology.
We're calling all pathology staff, faculty, and students, to enter their original artwork in any medium and any theme for consideration in display in this exhibit. Enter your work by April 15th at http://bit.ly/PathEmployeeArt18
We look forward to highlighting the talents of our Department of Pathology teammates in this exhibit that will run from mid-May to December 1st.
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Breast team reviewing a patient's slide. (From left to right) Ghassan Allo, Fellow; Laura Walters, Clinical Lecturer; Celina Kleer, Professor. See Article
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Autopsy Technician draws blood while working in the Wayne County morgue. See Article
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Dr. Sriram Venneti, MD, PhD and Postdoctoral Fellow, Chan Chung, PhD investigate pediatric brain cancer. See Article
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Director of the Neuropathology Fellowship, Dr. Sandra Camelo-Piragua serves on the Patient and Family Advisory Council.
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Residents Ashley Bradt (left) and William Perry work at a multi-headed scope in our new facility.
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MLabs, established in 1985, functions as a portal to provide pathologists, hospitals. and other reference laboratories access to the faculty, staff and laboratories of the University of Michigan Health System’s Department of Pathology. MLabs is a recognized leader for advanced molecular diagnostic testing, helpful consultants and exceptional customer service.