QUALITY IMPROVEMENT
AND EDUCATION
IN ANATOMIC PATHOLOGY.
DRAFT COPY ONLY.
(Procedure 35).
http://www.netautopsy.org/axsop/axsop035.htm


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United States Government Work, uncopyrighted, public-domain, DRAFT COPY ONLY. This document does not necessarily represent the views or policies of any United States Government agency. This document is provided "as is", without warranty of any kind, express or implied, including but not limited to the warranties of merchantability, fitness for a particular purpose and non-infringement. In no event shall the authors be liable for any claim, damages or other liability, whether in an action of contract, tort or otherwise, arising from, out of, or in connection with the document or the use or other dealings made with the document.

See also: Quality improvement program: 33, 34, 113, 137, 138.



PRINCIPLE OF THE TEST.

Maintenance of high-quality of service for optimal patient care.



SPECIMEN REQUIRED.

All human tissue excised at surgery, outpatient clinics, and postmortems, fresh or in fixative, along with a filled-out Tissue Examination Form (U. S. Standard Form 515, USSF515).



REAGENTS, INSTRUMENTATION.

VistA® computer system. Internet connection within the VA firewall.



TABLE OF CONTENTS.
1. Quarterly Assessment, Armed Forces Institute of Pathology.
2. Cytology proficiency testing.
3. Peer review in surgical pathology.
4. Monitors: turnaroud time.
5. Communications.
6. Timeliness.
7. Daily surgical pathology QI conference.
8. Enrollment in pathology review programs.
9. ASCP VA-cytopathology QA instructions.
10. AFIP surgical pathology QA instructions.
11. Employee required training instructions.
12. Reviewing prior surgical/cytopathology cases.
13. Protocol for handling disparities, errors.
14. Policy for documenting intradepartmental consultations.
15. Policy for documenting extradepartmental consultations.
16. Policy for documenting extradepartmental consultation discrepancies.
17. Coding extradepartmental consultations.
18. Turnaround time pilot study.



STEP-BY-STEP DESCRIPTION.


1. QUARTERLY QUALITY ASSESSMENT IN ANATOMIC PATHOLOGY BY THE ARMED FORCES INSTITUTE OF PATHOLOGY (AFIP). Unknown cases distributed by the AFIP are discussed at the daily Surgical Pathology QA conference. The consensus of opinions is returned to and evaluated by the AFIP. Any discrepancies are analyzed at the conferences for future references.

2. CYTOLOGY PROFICIENCY TESTING. The VA conducts its own cytopathology proficiency testing. The test is conducted by central office at intervals and dates chosen by central office. Compliance consists of complying with the set of instructions that accompany each test. All the anatomic pathologists who sign out cytology specimens are required to participate. Issues relating to actions taken as the result of proficiency scores are determined and acted upon by central office. Additional proficiency testing is conducted by the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytopathology and the American Society for Clinical Pathology CheckPath Cytopathology.

3. PEER REVIEW IN SURGICAL PATHOLOGY.


3.1. All microscopic tissue examinations of surgical tissue are performed by a staff pathologist and all surgical tissue diagnoses are made by a staff pathologist.



3.2. Each day, all pathologists participate in our QA conference at the multi-headed microscope, and review 100% of the biopsy and rush cases received. This includes review of frozen section diagnoses where there are any discrepancies between intraoperative diagnosis and final diagnosis; and all new cancer diagnoses. An attendance record is kept. Unresolved differences of opinion are recorded and can be sent to an outside consultant for review (usually the AFIP).



3.3. Every surgical pathology and cytology report is reviewed for any errors (in identification or completeness) and delinquencies. This review occurs at the time of report release (to the VistA® Computer System) by the pathologist who signs the case, and by the CHIEF, SURGICAL PATHOLOGY SECTION , who issues a lateness monitor.


4. MONITORS. All reports are reviewed, signed, and released, by ELECTRONIC SIGNATURE to the VistA® Computer System. Simple ("routine") cases are completed within two working days. The turn-around time for surgical pathology cases is followed by two monthly monitors to assure report timeliness. One monitor is prepared for the Invasive Procedures Review Committee (IPRC). The other monitor is prepared as a monthly QA monitor for the CHIEF, PATHOLOGY AND LABORATORY MEDICINE SERVICE.

The INVASIVE PROCEDURES REVIEW COMMITTEE (IPRC) REPORT monitors the numbers of cases and specimens accessioned into histology and cytology and reports on turn-around time for the month covered. CHIEF, QUALITY ASSURANCE SECTION , presents pathology findings each month at the IPRC, and these findings become part of the official IPRC minutes, which are forwarded to the EXECUTIVE COMMITTEE OF THE MEDICAL STAFF.

Pathology monitors the turn-around time for pathology reports of the month covered and documents specifically any cases that exceed a seven working day turn-around threshold. When a case exceeds this threshold, the attending pathologist signing the case must prepare a written explanation for the case's delay, and suggest any remedies that might help keep such a delay from recurring. Any discrepancies and errors found on review during the daily QA conferences are documented in this monitor.

Typical mean turn-around times for surgical pathology reports is 2.5 days (this includes large cases, such as colons, necks, stomachs, bladders, etc.), and the typical mean turn-around time for cytology specimens is about 1.5 days. The VistA® computer system can prepare turn-around statistics for any designated range of dates at any time. "Routine" cases, that require no special studies or dissections, are signed out within two days.

5. COMMUNICATIONS. Quality control issues are documented in the monthly surgical pathology and cytology QA monitors, and discussed at the monthly staff meeting.

      Physicians are notified in person, by telephone, or by confirm/priority email, for the following purposes:
5.1. Notification of a new positive (for cancer) diagnosis, with the exception of basal cell carcinoma.

5.2. Notification of unsatisfactory specimens.

5.3. Notification for clinically significant, unsuspected results, or any other issues of concern to the pathologist, such as unexpected positive margins in a resection; or unexpected infectious disease.
In the case of a confirm/priority email, the subject line must contain the words URGENT PATHOLOGY REPORT, and the case-number, so that the case can be tracked for reporting to the monthly Invasive Procedures Review Committee.

      The act of notification is dated, and included as part of the COMMENT section of the surgical pathology or cytology report, in which the new-positive or unsatisfactory report appears, and is also SNOMED-coded, as appropriate, as follows:

 P-0650  .......... CONSULTATION, NOS
 P-0658  .......... CONSULTATION, BY EMAIL
 P-0659  .......... CONSULTATION, BY TELEPHONE


      The VistA® computer email system has several advantages regarding communication and documentation of these notifications. A priority tag can be added to the email. When the person receiving the email logs onto the VISTA Computer System, a notice immediately comes to their attention informing them that priority email has arrived. A confirmation tag can be added to the email that is sent back to the pathologist when the email has been read, documenting to the pathologist that notification was read. The email can be queried to determine when, if ever, the email was read, if there is any doubt. The email can be forwarded to the section or department chief of the physician who submitted the specimen. The email provides legal documentation of physician notification. Finally, unresponded-to emails with the subject line containing the words URGENT PATHOLOGY REPORT may be tracked (see Procedure 138. Invasive Procedures Review Committee.

Our department has more than 15 years experience with email notification, and we have found it to be superior to all other forms of notification, including telephonic notification, because it provides legal documentation of the notification, and because notification is almost always successful.

6. TIMELINESS. Cases which are not signed out within seven working days after receipt of the specimen are considered delinquent. For the cases which require outside consultation, preliminary reports are issued.

7. DAILY SURGICAL PATHOLOGY QI CONFERENCE. A Surgical Pathology Quality Improvement conference is held daily. All biopsies are reviewed at the conference. The conference records are kept in the Office of the Chief, Surgical Pathology Section.

8. ENROLLMENT IN PATHOLOGY REVIEW PROGRAMS. The laboratory is enrolled in (1) the ASCP VA-Cytopathology Quality Assurance Program; (2) in the VA-Cytopathology Proficiency Program; (3) in the ASCP Cytopathology Checkpath program; and (4) in the Histopathology Quality Assessment Program (HQAP) administered by the Armed Forces Institute of Pathology (AFIP).

9. For the ASCP VA-Cytopathology Quality Assurance Program, signon to website:
9.1. Click on: http://www.ascp.org/cpimages

9.2. Click on:
Option 2
Download images in PowerPoint presentation (high-resolution):
Cytopathology - Quarter 1 (or other Quarter as appropriate).
9.3. Inside the VA firewall, a security banner will appear. You may have to wait up to 30 seconds.

9.4. Click on SAVE.

9.5. A SAVE AS box will appear. Again, click on SAVE (lower right corner of box).

9.6. Wait up to 20 seconds, and click on OPEN.

9.7. Click on the thumbnail slides on the left panel, so that the full slide will appear in the center.

9.8. Take the test on your paper document.

9.9. BE CAREFUL! Typically, the ASCP slides are placed out-of-order in the Powerpoint module, to test whether the pathologist is alert to the correct number for each case.

9.10. To end the session, click on the [X] on the upper right corner of the monitor-screen.


10. All attending pathologists at the Baltimore VAMHCS are registered for the VA Quality Assessment in anatomic pathology administered by the Armed Forces Institute of Pathology (AFIP). These pathologists should already have a LOGIN ID and PASSWORD available.
10.1. To begin or continue with a course, go to URL:
http://www.afip.org


10.2. Click on: ONLINE PATHOLOGY SERVICES (tab at top right of screen).

10.3. Inside the VA firewall, a security banner will appear. You may have to wait up to 30 seconds. If a SECURITY ALERT box appears, click on: OK.

10.4. Enter your LOGIN ID and PASSWORD (lower right box), and click on LOGIN.

10.5. On the left side of the screen, and click on: ONLINE PATHOLOGY.

10.6. Click on: EDUCATION.

10.7. Within the Course Search Box (Gray box), Scroll down to Course Type.

10.8. Hit the drop down error, and select Virtual Slides Courses.

10.9. Then click search Select the Histopathology Quality Assessment Program.

10.10. Select Conference 2-2007, or whatever is appropriate.

10.11. For questions, contact:
Nicole L. Jenkins
Office of Quality Assurance,
Armed Forces Institute of Pathology (AFIP)
Voice: 202-782-2649
Fax: 202-782-7347
email: jenkinsn@afip.osd.mil


10.12. Under VIRTUAL SLIDE COURSES, click on: HISTOLOGY QUALITY ASSESSMENT PROGRAM (HQAP) (bottom left).

10.13. At the bottom of the screen, SELECT A CONFERENCE BELOW:

10.14. Select CONFERENCE 1 (or other appropriate CONFERENCE, corresponding to the particular open season. That is, Conference 1 = February; Conference 2 = May; Conference 3 = August; and Conference 4 = November.

10.15. Each open season runs throughout the month, and you may change your diagnosis at any time up to the closing date. For example, the responses for Conference 1 may be entered or modified any time between February 1 and February 28.

10.16. Click on: CLICK HERE FOR VIRTUAL SLIDE. There may be a slight delay, due to slow transmission of the computer image during peak hours.

10.17. A separate slide image screen appears as a large image in the center with control buttons on the bottom; and as a smaller image in the upper left corner. Click [+] for increased magnification. The area of magnification appears as a [RED BOX] in the smaller image. You may manipulate the slide by left-clicking the mouse on the area of interest, and dragging the mouse around. You may drag either the small image or the large image.

10.18. Click [-] for decreased magnification. The CURSOR KEYS are: to move RIGHT; to move UP; to move LEFT; to move DOWN. DO NOT USE , as this action might back you out of the session. Click [↖] (leftmost button) to reset the image to its original appearance.

10.19. When you have examined all slides for a case, then enter your diagnosis in the DIAGNOSIS BOX, and click on SUBMIT DIAGNOSIS.

10.20. You have all month to submit a diagnosis, or modify an existing diagnosis. You may modify a diagnosis until February 28 for Conference 1, May 31 for Conference 2, etc.

10.21. When you have reached a stopping point, PRINT a copy of your work, for your records.

10.22. To obtain your CME records, repeat steps 10.1 through 10.4. On the left side of the screen, and click on MY CME. In the middle of the screen select REPORTING YEAR. Click on CME CERTIFICATE. PRINT the page for your records.


11. ALL-EMPLOYEE REQUIRED TRAINING BASIC GUIDELINES. You need a CYBER LOGIN/PASSWORD and a CARELEARNING LOGIN/PASSWORD. The CYBER LOGIN/PASSWORD requires a combination of at least three of upper case letters, lower case letters, numerals, or punctuation. The CARELEARNING LOGIN is the first letter of your given name (first name), first four letters of your surname (last name) all lower case, followed by the last four numerals of your social security number. The CARELEARNING PASSWORD is your given name, all lower case.

The learning modules are quite good, but getting your credits logged into TEMPO (which is the last and most important step of the required training) is different for different modules, and amazingly frustrating. Here are some observations:
1. If you see a certificate or some document indicating completion, PRINT IT IMMEDIATELY. This may be your only proof that you completed the learning module. The systems are flaky, and the next page may be an annoying unintelligible error message. When all else fails, give copies of these documents to your departmental administrator.

2. Just because your password worked the last time, doesn't mean that it works now. The system even changes the rules for what works as a password, without notifying the user.

3. Different logons have different password rules. Some require a combination of upper/lower case letters, numerals, and/or punctuation; some require at least 8 digits, etc., etc.

4. The first page of the Carelearning solicits your email comments, but provides no email addresses.
Here are the required modules:
Diversity Training:
http://vaww.vamhcs.med.va.gov/Departments/EEO/training/WhyDiversity.ppt
No password required. Certificate at end of presentation.

Sexual Harassment, Prevention:
http://vaww.vamhcs.med.va.gov/Departments/EEO/training/SexualHarassment.ppt
No password required. Certificate at end of presentation.

No FEAR:
http://vaww.vamhcs.med.va.gov/departments/eeo/training/nofear.ppt
No password required. Certificate at end of presentation.

Green Environmental Management System (GEMS):
http://vaww.vamhcs.med.va.gov/Training/gems/GEMS.ppt
No password required. Certificate at end of presentation.

VHA Privacy Policy:
https://vaww.ees.aac.va.gov/
Cyber login/password required. Certificate at end of presentation.

VA Cyber Security Awareness:
https://vaww.ees.aac.va.gov/
Cyber login/password required. Certificate at end of presentation.

Disaster & Emergency Preparedness:
http://vaww.vamhcs.med.va.gov/Training/carelearning.htm
Carelearning login/password required. Verification is automatically logged into TEMPO.

Fire Safety and Fire Extinguisher:
http://vaww.vamhcs.med.va.gov/Training/carelearning.htm
Carelearning login/password required. Verification is automatically logged into TEMPO.

General Safety:
http://vaww.vamhcs.med.va.gov/Training/carelearning.htm
Carelearning login/password required. Verification is automatically logged into TEMPO.

Hazard Communication (Hazardous Materials):
http://vaww.vamhcs.med.va.gov/Training/carelearning.htm
Carelearning login/password required. Verification is automatically logged into TEMPO.

Infection Control:
http://vaww.vamhcs.med.va.gov/Training/carelearning.htm
Carelearning login/password required. Verification is automatically logged into TEMPO.

Compliance:
http://vaww.vamhcs.med.va.gov/Training/carelearning.htm
Carelearning login/password required. Verification is automatically logged into TEMPO.

Affirming the Commitment: Opening Hearts to Veterans:
http://vaww.va.gov/atc/images/atc_intranet.asx
No password required. You have to have AUDIO on your computer, and turn up the VOLUME so you can hear the presentation.

SUMMARY OF CARELEARNING CLASSROOMS:
Abuse and Neglect Classroom.
Age Specific Care Classroom.
Blood Borne Pathogens Classroom REQUIRED.
Disaster Preparedness Classroom REQUIRED.
Electrical Safety Classroom REQUIRED.
Fire Safety (R.A.C.E.) Classroom REQUIRED.
Green Environmental Management System (GEMS) Awareness Classroom.
Hazard Communications Plan Classroom REQUIRED.
Moving and Lifting Classroom REQUIRED
Patient Rights Classroom.
Restraints & Seclusion Classroom.
Slips, Trips, and Falls Classroom REQUIRED.
Standard Precautions Classroom REQUIRED.
TB Prevention Classroom REQUIRED.
VISN 5, Compliance & Business Integrity Training Classroom REQUIRED.
How to Contact Your VISN 5 Compliance & Business Integrity (CBI) Office:
Ms. Donna Custer.
Donna.custer@va.gov
1-800-759-8888 PIN: 1064942.


12. REVIEWING PRIOR SURGICAL PATHOLOGY AND CYTOLOGY MATERIAL. The VistA® Computer System prints out the cumulative summary of prior surgical pathology, cytology, and electron microscopic reports rendered on the patient. Prior material relevant to the current biopsy is always reviewed, and a comment is placed directly in the surgical pathology report or the cytology report indicating the accession number of the case reviewed and whether it was concurred with. Examples of prior relevant material might include the prior biopsy of a basal cell carcinoma when a negative re-excision specimen is received (this confirms that basal cell carcinoma was actually present at the site of re-excision), and prior negative cytologies on a patient with an new atypical cervical Pap smear.

13. PROTOCOL FOR HANDLING DISPARITIES OR ERRORS IN DIAGNOSIS, including surgical, cytology and frozen section specimens. Significant disparities require the following steps:
13.1. The final report must specify the disparity.

13.2. The clinician submitting the specimen must be notified of the disparity.

13.3. The final report must document that the clinician was notified of the disparity.

13.4. The disparity must be discussed at the daily QA conference.

13.5. The disparity must be documented in the monthly pathology monitor submitted to the CHIEF, PATHOLOGY AND LABORATORY MEDICINE.


14. POLICY FOR INCLUDING INTRADEPARTMENTAL CONSULTATIONS IN REPORTS. It is the policy that all biopsies, all cytology specimens diagnosed as LGSIL or above, and all new cytology positive diagnoses, undergo intra-departmental consultation. In practical terms, this means that about 70% of all specimens received are reviewed by all the anatomic pathologists at QA conference. In addition, all difficult skin cases are reviewed by a dermatopathologist credentialed in the VA. All cases for which there is unresolved disagreement between pathologists, or that were considered considered difficult in the sense that the original diagnosis of the signing pathologist was not immediately accepted by all the members of the group conference, are commented directly in the surgical pathology report. An example of such a comment might be: "This case was reviewed the Chief, Dermatopathology Section, who concurs," or "This case was reviewed the Chief, Dermatopathology Section, who concurs, and adds that erythema multiforme should be included in the morphologic differential diagnosis," or "This case was reviewed by all the anatomic pathologists, who concur with the final diagnosis."

15. POLICY FOR EXTRADEPARTMENTAL CONSULTATIONS. Extra-departmental consultations are handled as follows:
      15.1. The consultation is delivered to the Chief, Surgical Pathology Section.

15.2. One copy of the consultation is added to a loose-leaf-bound collection of consultations kept in the department.

15.3. One copy is attached to the copy of the report that is kept in the Department.

15.4. The findings of the consultation are summarized by the staff pathologist for the case, as a supplemental report.

15.5. If the results of the consultation are of consequence to the clinicians caring for the patient, or if the clinician is waiting for the results of the report for any reason, the clinician is notified of the result of the consultation and the notification is documented as a supplemental report.
16. IF THERE IS A DISCREPANCY BETWEEN THE CONSULTANT DIAGNOSIS and the diagnosis rendered in our department, the case is reviewed at surgical pathology QA conference, and a supplemental report is written according to the consensus reached by all the pathologists.

17. CONSULTATION CASES are all SNOMED-coded (the consultation code is 3005), and can be retrieved at any time via SNOMED search.

18. TURNAROUND TIME PILOT STUDY. A Turnaround time pilot study was performed for the period July 1, 2001, through September 30, 2001. During this time, surgical pathology specimens numbered BSP 01-2602 through BSP 01-3717, a total of 1116 specimens, were logged into the Baltimore VAMHCS anatomic pathology system. Of these, 749 (67%) were "routine" specimens, that is, small biopsies that required only a single hematoxylin-eosin slide for diagnosis. The remaining 367 (33%) specimens were either large specimens, or required special stains, consultation, or some other form of detailed workup. The 749 "routine" specimens included 340 (45%) processed in one day, 341 (46%) processed in two days, and 68 (9%) processed in three days.



REFERENCE.


1. Rosai J.
Rosai and Ackerman's Surgical Pathology. Ninth Edition.
St Louis: C.V. Mosby. 2004;:.
ISBN: 0323013422, 3080 pages.

2. Mills SE, Carter D, Greenson JK, Oberman HA, Reuter VE, Stoler MH, eds.
Sternberg's Diagnostic Surgical Pathology. Fourth Edition.
New York: Lippincott Williams & Wilkins. 2004;:.
ISBN: 0781740517, 3089 pages.

3. Bonfiglio TA, Somark TM.
ASCP Educational and Proficiency Testing Programs in Cytopathology.
Lab Med. 1994;25:245-247.