INVASIVE PROCEDURES REVIEW COMMITTEE.
DRAFT COPY ONLY.
(Procedure 138).
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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.



PRINCIPLE OF THE TEST.

      Criteria for review of cases presented by pathology before the INVASIVE PROCEDURES REVIEW COMMITTEE (IPRC). There is a review for quality and appropriateness of specimens sent to pathology. If any of the pathologists expresses a concern regarding any case, utilizing nine established criteria, then the case is identified, and is brought to the Invasive Procedures Review Committee (IPRC).



STEP-BY-STEP DESCRIPTION.

      1. There is a 100% review of all anatomic pathology cases, including both surgical pathology and cytology. At least two anatomic pathologists meet daily, and review all cases. If any of the pathologists expresses a concern regarding any case, utilizing nine established criteria that might have a significant impact on patient care, then the case is identified, and is brought to the Invasive Procedures Review Committee (IPRC) for evaluation by the CHIEF, QUALITY ASSURANCE SECTION. The established criteria are listed below:
      1.1. Significant preoperative and postoperative diagnosis.

      1.2. Pathology diagnosis fails to support preoperative and postoperative diagnosis.

      1.3. Unexpected neoplasm discovered.

      1.4. Inappropriate removal of tissue.

      1.5. Surgery performed was based on previous biopsy material or outside diagnosis in which a VAMHCS-credentialed pathologist did not review the slides.

      1.6. Frozen section diagnosis differs significantly from the final pathology diagnosis.

      1.7. Specimen expected from the procedure, but was not received in pathology.

      1.8. Missing or inaccurate history information provided to the pathologist.

      1.9. Handling issues or other issues regarding tissue specimens that cause concern to the pathologist.


      2. The following statistics are reported each month to the IPRC meeting:
1. Surgical Pathology turnaround time (average; cases >7 days).

2. Surgical Pathology cases with internal consultation (SNOMED PROCEDURE codes P030122, P030125, P030112, P030123, P0658, P0659, P0655, P0650).

3. Surgical Pathology cases with external consultation (SNOMED PROCEDURE code P030112).

4. Surgical Pathology cases requiring supplement, that are not supplemented after one month.

5. Surgical Pathology cases requiring TNM SNOMED codes that have no TNM SNOMED code. (SNOMED PROCEDURE codes P0302...).

6. Cytopathology turnaround time (average; cases >7 days).

7. Cytopathology cases with internal consultation (SNOMED PROCEDURE codes P030112, P030125, P030112, P030123, P0658, P0659, P0655, P0650).

8. Cytopathology cases with external consultation (SNOMED PROCECURE codes P030112).

9. VistA® URGENT PATHOLOGY REPORT not responded-to.

10. Frozen section report NOT READ BACK.
EXPLANATORY NOTES: The above quality monitors 1,2,3,5,6,7,8 are obtainable by authorized personnel from the ANATOMIC PATHOLOGY MENU in the VistA computer system.
Turnaround time statistics (1,6) are under ANATOMIC PATHOLOGY SUPERVISOR, QA (=quality assurance), TT (=turnaround time).
SNOMED code summary reports (2,3,5,7) are under INQUIRY, SEARCH, BY PROCEDURE, with appropriate SNOMED codes as indicated above.

QUALITY MONITOR 4 is not supported by VistA®, but is downloaded each month as a Microsoft® Access database, by the CHIEF, CLINICAL INFORMATICS. Unsupplemented surgical pathology reports requiring supplement are tracked in the Clinical Informatics Microsoft® Access Database, as follows: each surgical pathology report whose MICROSCOPIC EXAM/DIAGNOSIS contains the character-strings PENDING or SUPPL, are followed to determine whether a SUPPLEMENTARY REPORT appears within one month of the SPECIMEN RECEIVED date.

QUALITY MONITOR 5 is initially collected from the Clinical Informatics Microsoft® Access database, and then verified in the SNOMED coding system, with SNOMED PROCEDURE codes for T0 (=P030201), T1 (=P030202), ..., N0, N1, ..., M0, M1, etc. Surgical pathology reports requiring TNM (Tumor-Lymph Node-Metastasis) SNOMED coding are tracked in the Clinical Informatics Microsoft(R) Access Database, as follows: each surgical pathology report whose SPECIMEN DESCRIPTION, BRIEF CLINICAL HISTORY, or GROSS DESCRIPTION contains the character-string ECTOMY are followed to determine whether a SNOMED TNM CODE (P0302...) appears within one month of the SPECIMEN RECEIVED date. A certain percentage of false positive cases (i.e., cases containing the text-string ECTOMY but not requiring a TNM code) are flagged by this Access Database procedure, to which are assigned the code UNCLASSIFIED TNM (=P030200). SNOMED PROCEDURE codes P0301... and P0302... are local codes used by the Baltimore Veterans' Affairs Maryland Health Care System.

QUALITY MONITOR 9 is all surgical pathology and cytopathology reports for which the pathologist issues a VistA® confirm/priority email with the subject line URGENT PATHOLOGY REPORT, which are unresponded-to after one month. The pathologist issues such a confirm/priority email on all new cancer cases, excluding basal cell carcinomas of the skin, or on any other case for which there is an apparently unexpected finding, including unexpected positive surgical margins, unexpected dysplastic lesions, new infectious disease, or other feature of concern to the pathologist. The fact that an email has been issued is documented in the COMMENT section of the report, and as SNOMED code P0658, CONSULTATION BY EMAIL. In preparation for each monthly report to the IPRC, the CHIEF, QUALITY ASSURANCE SECTION obtains the following listing of URGENT PATHOLOGY REPORTS that have not be responded-to, as follows: 
 Select LABORATORY MENU Option: PRINT Pathology Messages not read
 Enter Start Date to look at messages: 9/1/2003  (SEP 01, 2003)
 Enter End Date to look at messages: 9/30/2003  (SEP 30, 2003)
 DEVICE: HOME//   VIRTUAL TERMINAL    Right Margin: 80//
            
 Message Subject                           Message #  Sender
 URGENT PATHOLOGY REPORT BCY 03-1234       12345678   PATHOLOGIST,JOHN Q
 URGENT PATHOLOGY REPORT BCY 03-5678       90123456   PATHOLOGIST,JOHN Q
 URGENT PATHOLOGY REPORT BCY 03-9012       78901234   SPECIALIST,MARY G
 URGENT PATHOLOGY REPORT BCY 03-3456       56789012   SPECIALIST,MARY G
 URGENT PATHOLOGY REPORT BSP 03-7890       34567890   SPECIALIST,MARY G
 URGENT PATHOLOGY REPORT BSP 03-1234       12345678   SPECIALIST,MARY G
 URGENT PATHOLOGY REPORT BSP 03-5678       90123456   SPECIALIST,MARY G
     
Select LABORATORY MENU Option:
Each patient/report is checked to determine whether some other electronic followup has been documented, such as a CPRS note from the same service that submitted the original report. If no such CPRS report is apparent, then the case is reported to the IPRC.
It is essential that the attending pathologist who sends out the email to the clinician include the exact words URGENT PATHOLOGY REPORT, as well as the case number (BSP 03-... or BCY 03-...), in the subject-line of the notification email, and include include the SNOMED Procedure code EMAIL (CONSULTATION, BY EMAIL) as a procedure code for that report. Otherwise, an unresponded-to email will not be picked up by this Quality Monitor #9.

QUALITY MONITOR 10 is all surgical pathology reports that contain a frozen section report (intra-operative consultation), in which is is not documented that the report was READ BACK during the operation. Each month, the gross description for a surgical pathology report that contains the text-string FROZEN and the text-strings READ and BACK, is SNOMED-coded FROZEN SECTION (P3082) and READ BACK (P0657).

However, a surgical pathology case that contains the text-string FROZEN but does not contain the text-strings READ and BACK, is flagged for review by the CHIEF, QUALITY ASSURANCE SECTION. If the free-text of the surgical pathology report nowhere indicates that the surgeon was informed of the intraoperative diagnosis, then the case is reported in monthly statistics for the Invasive Procedures Review Committee.

For the calendar-year 2004, the statistics are as follows:
Non-read-back frozen section reports:
January, 2004: 3/13.
February, 2004: 0/13.
March, 2004: 0/15.
April, 2004: 0/16.
May, 2004: 0/12.
June, 2004: 0/11.
July, 2004: 0/10.
August, 2004: 0/17.
September, 2004: 0/9.
October, 2004: 0/14.


REFERENCES.

1. Rothwell DJ, Côté RA, Brochu L.
The Systematized Nomenclature of Human and Veterinary Medicine. SNOMED International. Microglossary for Pathology.
Northfield, IL: College of American Pathologists. 1993.
Voice: 1-708-446-8800. Fax: 1-708-446-8807.
ISBN not stated, 475 pages.

2. Percy C, Van Holton V, Muir C, eds.
International Classification of Diseases for Oncology. Second Edition.
Geneva: World Health Organization. 1990.
ISBN 92-4-154414-7, 144 pages.

3. O'Leary TJ.
Advanced Diagnostic Methods in Pathology. Principles, Practice, and Protocols.
Philadelphia: Saunders. An imprint of Elsevier Science. 2003.
ISBN 0-7216-4976-9, 540 pages.