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POSITION STATEMENT
MEDICAL DIRECTOR OF LABORATORIES RESPONSIBILITIES AND ROLE
Prepared by: Dr. G. Hoag and Dr. J. Wm. Ibbott
This position statement was reviewed and approved by the CAP Executive,
September 25, 1996. Published in the September/October 1996 issue of CAP
Newsletter.
This position statement was reviewed by the CAP Executive, July 3, 2004 – no
changes. THE MEDICAL LABORATORY DIRECTOR
The medical director of the laboratory is a suitably qualified physician who is
legally, morally, and ethically responsible for the scope, standards, and
quality of service. The medical director has the knowledge and skills in all
areas of practice which includes administration, teaching and education,
research, and patient care. The director stands responsible for medically
useful, accurate information made available in a timely fashion to enhance
medical services to patients. The director participates in all managerial
decisions and guides the operation of the laboratory ranging from selection of
staff, choice of methods, purchase of equipment, quality assurance, quality
control, safety, hours of operation, scheduling of staff, and utilization
management. The director complies with the College of Physicians and Surgeons
(provincial) and Canadian Medical Association (CMA) Code of Ethics.
Standards
The laboratory director shall be aware of and perform the duties and
responsibilities of the position consistent with standards of accreditation of
laboratories that exist at a national or provincial level. The standard of
practice shall be consistent with the College of Physicians and Surgeons in each
jurisdiction by suitably qualified individuals able to assume professional,
scientific, consultative, organizational, administrative, and educational
responsibilities for the service. The Director Shall:
- have sufficient authority to implement and maintain the
standards
- define and monitor accepted standards of performance and
direct the implementation of laboratory services
- function as a peer member of the medical community
- support medical staff functioning as in integrated team,
personally demonstrating leadership and team qualities
- assist in the interpretation and correlation of
laboratory data for patient management
- establish short and long term goals and allocate the
appropriate resources
- provide cost-effective administration of all laboratory
services
- provide educational direction for the medical and
laboratory staff
- communicate effectively with accrediting, licensing, and
regulatory bodies and maintain effective communication with the local board
of directors of the hospital or institutional administration
A - THE ROLE OF THE DIRECTOR AS SERVICE PROVIDER
- Medical significance, interpretation, and correlation
of data. Make judgments about the medical significance of clinical
laboratory data and communicate effectively in interpreting laboratory
data and relating correlations to referring physicians as appropriate.
- Direct Service
Personally perform a variety of services expected of a laboratory
physician, e.g.: surgical pathology, autopsies, frozen sections, bone
marrows, needle biopsies, etc.
- Consultations
Provide consultations to physicians regarding the medical significance
of laboratory findings and utilization of the laboratory as appropriate.
- Medical Staff Privileges
Serve as a member of the medical staff as appropriate, for those
facilities served.
- Interaction With Physicians/Patient/
Administrators/Agencies
a. Relate and function effectively with
applicable accreditation and regulatory agencies, the medical
community and the patient population served.
b. Stand responsible to the hospital board through the
administrator or to the agency owning the laboratory for the
effective functioning of the laboratory where applicable.
- Standards of Performance
Define, implement, and monitor accepted standards of performance in
quality control, quality assurance, and cost-effectiveness of the
laboratory service.
- Monitoring and Correlation of Laboratory Data
Monitor all work performed in the laboratory to determine that
reliable medical data are being generated; correlate laboratory data
for diagnosis and patient management.
- Appropriate and Timely Service
Stand responsible for the appropriate and timely response of the
laboratory to physicians requests for testing plus the appropriate
and timely reporting of results. Document compliance with national
or provincial utilization protocols pertaining to laboratory
services.
- Quality Assurance Responsibilities
Assure that the laboratory participates effectively in the quality
assurance program of the institute.
- Personnel
Ensure there are sufficient qualified personnel with adequate
training and experience to supervise and perform the work of the
laboratory.
- Strategic Planning
Perform planning for setting goals and allocation of resources
appropriate to the medical environment. (Where appropriate in
conjunction with the medical staff and administration of the
hospital or institution).
- Administrative and Management Responsibilities
Provide effective and efficient administration of the service
including budget planning and control. (Where appropriate in
conjunction with the administration of the hospital or institution).
Certify and monitor accuracy of information used for third party
payments. Promote a stimulating environment for team members to
maintain a high quality of laboratory service.
- Education Responsibilities
Provide educational direction and opportunities for the medical and
laboratory staff, and participate in educational programs of the
institution as appropriate.
- Research and Development Responsibilities
Plan and direct research and development appropriate to the
facility.
- Reference Laboratories
Select all referral laboratories.
- Safety Responsibilities
Promote a safe laboratory environment for personnel and other
occupants.
- Ethical Responsibilities
Promote practices that are consistent with accepted ethical
standards for the medical profession.
B - DELEGATION OF RESPONSIBILITIES
The director need not perform all responsibilities personally.
Administrative functions may be delegated to qualified laboratory
managers and supervisors. Medical and technical responsibilities may
be delegated to physicians and other qualified laboratory personnel
as appropriate. The director, however, remains responsible for the
overall operation and
administration of the laboratory to ensure that quality patient care
services are provided. The qualification of the medical director
should be consistent with the primary role of the laboratory.
C – PERSONNEL
- Staff Complement
There shall be a sufficient number of qualified laboratory
physicians, laboratory technologists, technicians, and other
laboratory staff to perform the required tests promptly and
efficiently. Staff morale should reflect reasonable workloads.
- Staff Qualifications
The director shall assure that all procedures and tests
performed by the medical technical staff are within the scope of
education, training, and experience of the individual(s).
- Staff Scheduling
Qualified technical staff shall be on duty, or available, at all
times that laboratory testing is being performed.
- Staff Education
Provision shall be made for all personnel, including physicians
and supervisors, to further their knowledge and skills through
on-the-job training, in-service education programs, or
attendance at workshops, institutes, and/or professional
meetings. In-service education programs shall be provided at
defined intervals appropriate for the size and needs of the
technical staff.
- Staff Orientation
An adequate orientation program must be in place. Documentation
of activities should be maintained.
D - ORGANIZATIONAL DUTIES
- Infrastructure
There is sufficient space, equipment, and supplies within
the pathology and medical laboratory services to perform the
required volume of work with optimal accuracy, precision,
efficiency, timeliness, and safety.
- Communications
There are channels of communication within the pathology and
medical laboratory services, with other departments/services
of the hospital and the medical staff, and outside services
and agencies which are appropriate for the size and
complexity of the hospital. Communication on patients shall
be accessioned, reported, and stored in confidential data
bases or registries.
- Documentation
There is documentation that the required records and reports
are maintained and, as appropriate, are filed in the
patient's medical record and in the pathology and medical
laboratory services. All records and reports are maintained
as confidential.
- Quality Assurance
There are quality control systems and measures of the
pathology and medical laboratory services designed to assure
the medical reliability of laboratory data. Such processes
are available for internal review and action plans and
resources appropriate to monitor effectiveness.
- Confidentiality
Processes within the pathology and medical laboratory
services shall be designed to assure confidentiality of
laboratory data. Systems shall be monitored for compliance
with accepted medical practices.
- Professional
There are sufficient resources to provide professional
coverage and remuneration for staff at a reasonable level.
Interpersonal relations should respect guidelines adopted by
the medical licensing authorities within Canada.
- Governance
Leadership in development and implementation of patient
focused laboratory services, including delivery systems that
optimize services to achieve the desired health outcomes for
patients.
Note:
Many of these statements are excerpts from the references
cited below:
American Society of Clinical Pathologists
(ASCP)
Alberta Society of Laboratory Physicians (ASLP)
College of American Pathologists (CAP)
British Columbia Association of Laboratory Physicians (BCALP)
Dr. Duncan Innes, Personal Communications
Medical Practitioners Act, BC
Ontario Medical Association (Section of Laboratory Medicine) |
