Histology Process Improvements and the Future of Standardization with Joelle Weaver
I had a great time interviewing Joelle Weaver about her career as a histotech. Here are some excerpts about histology process improvements for laboratory efficiency, quality management, and the future of standardization in histology.
What is it like to be a histotech?
It entails a lot more than people imagine it does. In clinical labs, each sample is like a snowflake. You’ll never see the same sample twice because it is part of the person it came from. Being a histotech is unique because it is very artisan like. First, it’s very hands on. Second, there is so much that’s done based on specific qualities of each particular sample, much more so than in other areas of medicine.
You have to have the right personality for it. You have to be detail oriented, but in a visual way. The things we’re dealing with are more or less qualitatively assessed. For some people, this would be too fuzzy and uncomfortable, but others like this artistic, individualistic aspect to it. There are many fine details that you need to be able to perceive and appreciate. You also need the ability to stay on task and concentrate intensely for patient safety and your safety. If you stop paying attention you could easily lose a sample or cut yourself.
One great thing is that there are thousands of different tests that you can do, and you could really spend your whole life learning all these methods. I like this part of being a histotech, because you don’t get bored – there’s always the chance to learn something completely new.
Why did you become a histotech?
It wasn’t a direct path. At the time I was a grad student in a Physician’s Assistant Program and I was doing a rotation in a pathology lab. The pathologist took a lot of time with me and allowed me to watch them do a variety of procedures. I couldn’t believe that I’d worked there for 8 years and I didn’t know this was going on! I thought it would be a lot more interesting than what I was currently doing so I found out where I could train. The pathologist helped me get a job and literally within 3 days I was relocated and ready to do it!
On working in different types of histology labs:
As a histotech, it’s nice to have options for different environments. I’ve worked in a lot of both low and high volume hospital labs. All clinical labs are fast-paced, but there’s quite a bit of difference between these two types of labs. In high volume labs you tend to do one or two tasks for the full work-day and get really good and fast at a couple of things. In smaller labs, you have to do everything because they have less staff. I currently work at PGXL Laboratories, which is quite unique.
Are there things you learned in one lab that you’ve applied in other labs?
I’m really interested in operations and process and like working in labs that are focused on this. When I worked at a lab in a 5 hospital system, they had a close competitor, so the two labs were vying for the greater market share. We had to be very efficient, cost-effective, and reduce waste. I internalized this early on in my career. To varying degrees of success, I’ve encouraged other labs to focus on these qualities. There’s more competition for every health care dollar than ever and this should be in the forefront of your mind if you’re influencing how a lab is run.
What sets PGXL laboratories apart from other labs?
PGXL is a clinical lab, but we’re also a CLIA high complexity lab. The majority of tests we do are ones where we’ve developed the entire assay in house. We develop a test system, characterize the results, validate it, and test it in patients. Most clinical labs don’t delve into this level of detail. The majority of clinical labs stick to well established testing and high volume throughput. We’re more like a reference lab in this regard.
PGXL has a focus on personalized medicine. How will personalized medicine change the way histology labs and histotechs operate?
That’s a question I’m grappling with right now. In a way, we’ve always done personalized medicine because each person’s sample is unique to them. PGXL takes this individuality down to a genetic level. A major challenge of personalized medicine is to determine the best treatment for each patient. Right now PGXL is developing algorithms to allow us to screen for patients who will benefit the most from esoteric testing. I think this is a major direction towards more personalized medicine.
In the future, to make medicine more personal, I’d like to see a report that explains everything – from the physicality of the tumor to the genetics – for the physician and the patient. People with cancer can be so overwhelmed – they get bits and pieces of information and no one synthesizes it for them. Pathology is something everyone can make sense of. We can use the tangibility of the pathological findings and connect them to the clinical ramifications for each patient.
You have a Lean Six Sigma Green Belt certification. What is this? How has it benefited the work that you do now?
In labs, you can often be running around putting out fires, but if you don’t take the time to get to the root of your problem, it will continue to recur. It’s interesting because often you’ll think the problem is one thing, but then through systematic analysis you’ll determine it’s something else completely. When implementing Lean Six Sigma, you collect front-line staff’s first-hand knowledge and utilize this rather than having someone walk into a lab once a month and make an anecdotal observation.
Lean is about eliminating waste while still creating a something of value for your customer. The idea was developed by Toyota. Six Sigma focuses on process improvements to minimize errors and reduce variability. It was developed by Motorola. Both are ways of looking at every dimension of your process in a very systematic way using statistical tools. Ultimately, Lean Six Sigma helps to identify the root cause of the fire you’re putting out and prevent it in the future. They also help to reduce inefficiencies and standardize your process. They provide a lot of structure and are very team oriented – everyone has to buy in.
Lab work is a linear process. It’s not exactly like manufacturing, but the application of Lean and Six Sigma does apply. What’s difficult with histology is that you have a lot of qualitative information that needs to be converted into quantitative metrics. It’s not a perfect fit, but it can help to transform the mindset of the lab. I like it because it’s a very effective tool when it’s implemented well and used appropriately.
How do you turn qualitative information into quantitative metrics in histology labs?
For example, when evaluating immunostains there are a number of different quality dimensions. Is it staining the appropriate targets in the correct location? Is there non-specific staining or background? Is the section quality good? Do you have a complete, representative section of the tissue? Are your positive and negative controls good? Then you need to make these qualitative assessments quantitative for your records of quality control. You can use these kinds of numbers to do a root cause analysis to determine the source of problems and inefficiencies.
You’re on the Quality Management Committee for the National Society for Histotechnology. What is quality management and why is it important?
Accuracy and timeliness are non-negotiable – but quality can be a bit subjective at the moment. So adding quality management to your lab is the process of going through each step and identifying what your quality standards are and then measuring those consistently. This allows employees to be very clear on what they need to produce.
Many people talk about histology being an art, but it is obviously very informed by science. Can you talk about the intersection of art and science in histology?
Because slides are created with your hands, people have an emotional connection to them. I definitely appreciate this aspect of histology and enjoy looking at slides. I think where they intersect is that the slide itself is a permanent picture in time – it’s the preservation of a moment for the patient.
If I had to pick, I’d come down on the side of science because I’m really interested in the information management aspect of it. The slide is a medium for pathologists to collect information about patients. Their interpretation drives actions taken for the patient and by the patient. The slide is the middle man and most people never see it.
But I honestly do go back and forth between the art and science of it…
How do you think histology will change in the next five years?
In an even shorter range than 5 years, there is a large push for standardization. There will be more validation, documentation and standardization of processes that have been very flexible in the past.
I also think most of the manual tasks of moving things from one step to the next will go away – this will all be done by automation. The technical work of histology won’t go away, but I think it will change…
What’s the most obscure thing you’ve ever cut?
The most memorable thing I’ve ever cut is a pediatric retinoblastoma. Sometimes they have to remove the entire eyeball and the whole thing needs to be sectioned. It takes 200 to 500 sections to get through it and it’s really difficult to cut. You need to keep every single section because they’re looking for the optic nerve. There is no do-over, so I was sweating bullets the entire time I was cutting it.
What’s the craziest thing that’s ever happened to you in the lab?
At the time I was working in a hospital that didn’t have an automatic cassette labeler. Someone labeled the cassettes using a regular marker and all the identifying information completely washed off! We ended up having to re-cut everything, assign it a new number, and then try to match the new recuts with the old ones using visual information as well as the gross description of the tissue. In the end, everything worked out OK for all the patients, but it took a lot of problem-solving to do it.