My last article stressed the concept of vector: the importance of aligned objectives and quantified measurement as prerequisites in guiding the utilization management culture within and beyond our Department of Laboratory Management and Pathology.
This month, we’re going to crank up the party, and I’m going to kick off a three-part series called, "Lessons from Leaders," where I’ll interview a thought leader in our practice about a key contribution he or she has led in our utilization management transition. I’m starting off with one of my favorites.
Amy Clayton, M.D., is a renowned anatomic pathologist and the Vice Chair of Clinical Practice and Quality for Mayo Clinic’s Department of Laboratory Medicine and Pathology. (She’s also the recently named Division Chair of Anatomic Pathology and just a darn nice person). Dr. Clayton is a visionary in the team process, and she was the driver behind one of the most prolific accelerators of integrated practice and patient-centered dialogue in our department’s utilization management transition: the disease-oriented group (or DOG, for short).
The DOG is a multidisciplinary team formed to establish a forum for the collegial discussion and decision making around the appropriate application of laboratory testing, pathology, and genetic profiling to best manage a particular condition. As an example, our Pulmonary Oncology DOG governs the test development, algorithms, and ordering rules for patients with lung cancer.
I’m motivated to cover this as a utilization management concept because I spent time as a product manager for Mayo Medical Laboratories’ Oncology Service Line and had the privilege of participating on select DOGs and seeing the dynamic firsthand. Let me explain.
The first DOG meetings were contentious—and this was a great thing—because long-overdue and passionate conversations were happening among previously under-connected teams of patient-care providers and administrators who needed such forums to share ideas, vent frustrations, and find common ground toward the best interests of the patient. After the initial "airing of the grievances," I was witness to a recurring gathering that yielded real-time practice change and the building of stronger relationships between our care teams. The DOG really has become the hub of our utilization management knowledge.
So let’s get onto my discussion with Dr. Clayton. I posed a couple of questions I suspect might be of interest to our readers and summarized her comments below:
How did you come up with the DOG concept?
"The DOG is not mine; it’s come from the work of many, especially including Kevin Halling, M.D., Ph.D., Co-Director of the Clinical Molecular Genetics Laboratory and Consultant in Laboratory Genetics and Clinical Genomics, Lynn Padley, Administrator of Quality Management Services and Practice in the Department of Laboratory Medicine and Pathology (DLMP, and Tim Plummer, Administrator of Operations in DLMP."
"The DOGs, as we know them today, were born from a concept that we saw successfully used on a smaller scale by our molecular cytology team to harness multidisciplinary expertise. We used their model as a template toward the larger program."
"As our practice expanded, we recognized that our size was inadvertently creating duplicative and misaligned efforts in test development. Our divisions were suffering from a ‘silo effect’ and like-minded thinkers from different divisions weren’t benefitting from the advantages of working together; or worse, they didn’t know the other existed."
"We weren’t taking advantage of our collective clinical expertise, and we weren’t engaging our clinicians effectively to understand exactly what information they wanted from us to best manage their patients. And, we weren’t fully engaging our product managers to understand how the users of our reference laboratory services would like to order testing to create a best fit with their care models."
What is the composition of a DOG, and who are the ideal participants from a role perspective?
This really varies by group. But, at a minimum, we’ve seen greatest success with representation from the following roles:
"With these people around the table, you’ve created a framework that provides the key representation to drive good decisions."
What has been the clearest benefit to the practice from the implementation of DOGs?
"We’ve created a new level of synergy across the practice, and we’ve modeled integrated decision making driven by the care of the patient."
"We’ve also accelerated academic contribution and improved cross-laboratory relationships by creating a venue for like-minded, but diversely skilled, health care professionals to address complex problems together."
What were the unforeseen challenges you’ve managed since implementing DOGs?
"There are many perspectives on the best way to drive integration and innovation, and not all of our staff initially saw the DOGs as advantageous. Some of our physicians and scientists felt most comfortable working alone and relished their autonomy and sovereignty to govern their labs. Or, they were guarded in sharing their research with others."
"Mayo Clinic is a very process-oriented practice, and some viewed this as an undesirable layer of bureaucracy and an affront to their time."
"Despite the positive outcomes, there was, and is, a change-management component to this and a cultural shift. Fortunately, we’ve had strong leaders of the DOGs pick up the mantle and really believe in the concept and drive that change."
Are there any evolutions of the concept you’re considering or actively pursuing?
"The collegial nature of the DOGs has really thrived, and we’re working to add management tools to continue to maximize the teams’ contributions to the practice. We’re in the late design stages of a tool that quantitatively weights and prioritizes test development based on a host of factors to measure the value of the test to the practice and reference laboratory business. This tool will integrate into our Product Lifecycle Management tool and ensure that each DOG’s multidisciplinary expertise is being harnessed in a structured way to allocate time and resources to areas of highest need."
What are a few tangible utilization examples that the DOGs have contributed to the practice?
"We have a tremendous depth of clinical expertise in the neuro-oncology space, and our DOG here, led by Caterina Giannini, M.D., Ph.D., Consultant in the Division of Anatomic Pathology, developed a custom genetic panel and set of utilization rules that changed society guidelines. Because of that collaborative effort and Dr. Giannini’s contributions in academic societies, the DOG output improved care, not only at Mayo Clinic, but for patients around the world."
"The leadership of Ben Kipp, Ph.D., Consultant in the Division of Anatomic Pathology, of our GI-oncology DOG has produced similar results. The team has developed novel next-generation sequencing panels that address clinically actionable mutations associated with Lynch syndrome and colorectal cancers. The test and the requisite expertise within the group has been used frequently for the treatment of Mayo Clinic patients and, through Mayo Medical Laboratories, is being used to improve the care of these patients quite literally around the world."
In this series, it’s my goal to share examples of steps we’ve taken at Mayo Clinic that have bolstered our utilization management efforts, but also, examples that I believe could easily be translated as a concept to be applied in the practices of our readers. We’ll keep it going next month with some words of wisdom from one of our other thought leaders. In the meantime, Dr. Clayton is one busy person, but if you have questions or comments, don’t be shy about dropping me a line, and I’ll dig up the answer.