Whether you send your pathology specimens to the hospital or to an independent pathology lab, you want accurate, concise reports, fast turnaround and committed service. Here are some of the details you should negotiate to get the most out of your pathology lab.

• Is it the surgeon's call? Your policy should state whether all tissue removed during the surgical procedure shall be sent to pathology or if the choice is at the surgeon's discretion. Your policy should also list exempt tissues (explanted breast implants and tonsils, for example). The surgeon may weigh in on whether a gross and microscopic examination or a gross-only examination is needed, but when a gross-only has been ordered, the attending pathologist may elect to submit the specimen for microscopic examination.
• Inside or outside? Even though you have many regional and national pathology labs to choose from - some of which are specialty-specific (GI and podiatry, for example) - your surgeons might prefer to stick with a local pathologist at the hospital.
• 48-hour turnaround. Getting path reports back before the patient comes in for his post-op visit is a need, not a want. A 48-hour turnaround should be the rule.
• Pathology report distribution. The lab should send reports of pathologic exams directly to physicians' offices. You'll want a copy of each report sent to your facility for inclusion in patients' medical records. Your medical records clerk should monitor the pathology book and the returned reports to assure that all specimens have been reported. This person should interact with the pathology department for any missing reports.
• Do you require on-site frozen section services? Path results may drive the case most often in ENT, general surgery and plastics. If you host a lot of these cases, frozen section examinations to direct further surgery will be performed at your facility. At least 24 hours before a pathologist is needed, your scheduler should call the path lab to confirm. The pathologist may report over the intercom to the surgeon if the patient is asleep, identifying himself, verifying the patient's name, the specimen number and site of origin before reporting the diagnosis. If the patient is awake, the circulating nurse will pick up the slip with the written report, carry it back to the room and show it to the surgeon, or the surgeon will come to the OR telephone for a verbal report from the pathologist. If you go with an off-site pathology service, arrange for a courier service (call before time of need whenever possible) to pick up double-bagged specimens for immediate delivery. Let your surgery scheduler know of the plans for the frozen specimen, including the method and location of reporting requested by the surgeon.
• Who's responsible for regulatory compliance? Make sure the lab you contract with is licensed and accredited and that its pathologists have their medical licenses and malpractice insurance. You'll also want a statement that your lab is in compliance with HIPAA regulations (what happens to the paperwork and the specimens once they leave your facility?). Also, will you have to credential pathologists individually to your medical staff or will your contract require they meet other regulatory requirements of your accrediting body and facility license?
• Who'll pay for supplies? Spell it out. You shouldn't pay for the technical portion of services (meaning you don't pay for the technician to prep the slide) or supplies (be it specimen cups or formalin).
• Who'll own and maintain the cryostat? Most times, your center will be charged with upkeeping the cryostat. Ensure proper training of the person(s) who'll perform daily checks and outsource more extensive maintenance to a clinical engineering company.
• Avoid exclusive clauses in contracts. Make sure you can use other pathology services for certain patients or situations. This can be important if a pathology group isn't contracted or has a dispute with a third-party payer for which you're a provider. Once, our pathology service was embroiled in a long negotiation with one of our major providers. Although the pathology service was very willing to work with patients individually to avoid large out-of-network pathology costs, several physicians wanted to use a different pathology lab on an interim basis to avoid any patient dissatisfaction. Similarly, don't sign anything more than a two-year contract and be able to cancel the contract without cause in 60 or 90 days.
• Peer review. You'll want your pathologists involved in your quality and peer review processes at your facility. Does the final diagnosis match the frozen section? Does the clinical diagnosis match the pathology diagnosis? Also, what kind of internal peer review program does your service have? For example, another pathologist should periodically review a certain number of his colleague's reports and specimens.

Who's reading your biopsies?
Just as anesthesia and radiology are facility-based physician services, so, too, is pathology. Your pathology service is fortunate to get your center's business and to be able to bill out its services. In exchange for your business, you should expect a certain level of service to your surgeons, your patients and your center. And don't forget the role of your own staff members in handling, documenting and tracking pathology specimens. It requires a team effort to provide exceptional pathology services.