ANATOMIC PATHOLOGY
PROCEDURE MANUAL.
SAMPLE QUESTIONS
AND PROCEDURES.

Intranet-Based Quality Improvement Documentation
at the Veterans Affairs Maryland Health Care System.

U. S. Government Work, published in Modern Pathology 2001;14:1-5.

Andrew Borkowski, MD. Dong H. Lee, MD. Debra L. Sydnor, CT (ASCP) IAC. Robert J. Johnson, MD, PhD. Albert Rabinovitch, MD, PhD. G. William Moore, MD, PhD.

Through an unfortunate oversight by the authors, the contributions of Jules J. Berman, PhD, MD, to our report on Intranet-based Quality Improvement Documentation were not credited in the original manuscript. Dr. Berman prepared the first electronic file that linked CAP review questions to the appropriate answers contained within departmental protocols. Our publication expanded this original body of work, formatting the revised file as an HTML document available on the VA intranet. Dr. Berman also participated in some of the early plans to port the file to the VA intranet, an effort that took place after he left the Baltimore VAMHCS to assume his current position as Program Director for Pathology Informatics, at the National Cancer Institute. We regret the omission.




ANATOMIC PATHOLOGY PROCEDURE MANUAL:
Jules J. Berman, PhD, MD. Andrew Borkowski, MD. Oscar A. Iseri, MD. Dong H. Lee, MD. G. William Moore, MD, PhD. Debra L. Sydnor, CT (ASCP) IAC.

RESPONSES TO CAP CHECKLIST.

QUESTION: 08:0200 PHASE: I
As applicable, is the laboratory enrolled in or has it attempted to enroll in a peer educational program in anatomic pathology (e.g., CAP APEX program)?

RESPONSE: YES, the laboratory is enrolled in CAP and ASCP pathology review programs, as well as the continuing education program contracted by the VA for Quality Assessment in anatomic pathology and administered by the Armed Forces Institute of Pathology.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08:1000 PHASE: II
Is the quality improvement program defined and documented for surgical pathology?

RESPONSE: YES, the quality improvement program is defined and documented for surgical pathology.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08:1005 PHASE: II
Whenever possible, is pertinent previous cytologic and/or histologic material from the patient reviewed with current material being examined?

RESPONSE: YES, all previous cytologic and histologic materials from the patient are listed on the printed report of the current material being examined. If pertinent, the previous material is reviewed, and this review is documented in the current report.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08:1010 PHASE: II
When significant disparities exist between frozen section and final diagnosis, are these reconciled in writing either in the surgical pathology report or in the departmental file?

RESPONSE: YES,
when significant disparities exist between frozen section and final diagnosis, this fact is reconciled in writing in the surgical pathology report.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08:1015 PHASE: II NEW
Does the laboratory have a policy for inclusion of INTRA-departmental consultations in the patient's final report?

RESPONSE: YES, the laboratory has a policy for inclusion of intradepartmental consultations.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08:1020 PHASE: II NEW
Are EXTRA-departmental consultations documented, and are records of these consultations maintained in a systematic manner within the pathology department?

RESPONSE: YES, extradepartmental consultations are documented on each report, and records of these consultations are maintained in a systematic manner with the Chief, Anatomic Pathology.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.


QUESTION: 08:1025 PHASE: I
When extra-departmental cases are submitted to the laboratory for consultation, are they accessioned according to the standard practices of the laboratory, a written report prepared, and a copy of this report sent to the original pathologist?

RESPONSE: YES, when extra-departmental cases are submitted to the laboratory for consultation, they are accessioned according to the standard practices of the laboratory, and a written report is prepared. Because of special regulations involving Veteran patients, a copy of this report is sent to the original pathologist only with a Release of Information document, signed by the patient.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08:1215 PHASE: II
Are reports on routine cases completed within two working days?

RESPONSE: YES, reports on routine cases are completed within two working days.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08:1245 PHASE: II
Is an index or cross-reference system in use to allow retrieval of information by patient name and/or diagnosis?

RESPONSE: YES, the VISTA computer system allows retrieval of information by patient name and by SNOMED-coded diagnosis.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08A:0075 PHASE: I
Do all personnel involved in cervicovaginal cytopathologic diagnoses participate in an interlaboratory comparison program?

RESPONSE: YES, all personnel involved in cervicovaginal cytopathologic diagnoses participate in an interlaboratory comparison program, supervised by the Veterans Affairs Central Office.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08A:0710 PHASE: II
Is there a documented policy for protecting and preserving the integrity and retrieval of original slides in cytopathology?

RESPONSE: YES, there is a documented policy for protecting and preserving the integrity and retrieval of original slides in cytopathology.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.



QUESTION: 08A:0880 PHASE: II
Is there documentation of each individual's diagnostic discrepancies and corrective action taken?

RESPONSE: YES, Supplementary reports are issued if a discrepancy occurs.
See PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.





ANATOMIC PATHOLOGY
PROCEDURE MANUAL.
TABLE OF CONTENTS.

PROCEDURE 1: MAIN OBJECTIVES OF THE HISTOLOGY LABORATORY.
PROCEDURE 2: RECEIPT OF SURGICAL SPECIMENS.
PROCEDURE 3: RECEIPT OF SURGICAL SPECIMENS.
PROCEDURE 4: SPECIMEN ACCESSIONING.
PROCEDURE 5: INSTRUCTIONS FOR SUBMITTING TISSUE TO ANATOMIC PATHOLOGY.
PROCEDURE 6: RULES OF ACCESSIONING.
PROCEDURE 7: ANATOMIC PATHOLOGY SYSTEM.
PROCEDURE 8: LOGBOOK INSTRUCTIONS.
PROCEDURE 9: EXAMINATION AND DESCRIPTION OF SPECIMENS.
PROCEDURE 10: FIXATIVES.
PROCEDURE 11: PROCESSING.
PROCEDURE 12: OPERATING THE TISSUE PROCESSOR MPV II.
PROCEDURE 13: DAILY TIME SCHEDULE - MVP II.
PROCEDURE 14: INSTRUCTIONS FOR STARTING MVP II.
PROCEDURE 15: CONDENSED HISTOMATIC INSTRUCTIONS.
PROCEDURE 16: EMBEDDING.
PROCEDURE 17: OLD EMBEDDING ILLUSTRATION SHEET. REMOVED 11/98.
PROCEDURE 18: CUTTING OR SECTIONING TISSUE.
PROCEDURE 19: BONE MARROW PROCEDURE.
PROCEDURE 20: DECALCIFICATION.
PROCEDURE 21: METHOD FOR REMOVING MERCURIC CHLORIDE CRYSTALS FROM TISSUE.
PROCEDURE 22: METHOD FOR RECOVERING MERCURY FROM FIXING FLUIDS.
PROCEDURE 23: PNEUMOCYSTIS AND FUNGUS PROTOCOL FOR MICROWAVE.
PROCEDURE 24: POLICY FOR SUBMISSION OF FROZEN SECTIONS.
PROCEDURE 25: FROZEN SECTION PROCEDURES (INTRAOPERATIVE CONSULTATIONS).
PROCEDURE 26: FROZEN SECTION STAINING PROCEDURE.
PROCEDURE 27: FROZEN SECTION PROCESSING AREA.
PROCEDURE 28: MICROTOME LUBRICATION.
PROCEDURE 29: FRESH LYMPH NODES.
PROCEDURE 30: BONE MARROW PROCESSING PROCEDURES.
PROCEDURE 31: OLD PROCEDURE FOR SERS CASES. REMOVED 4/99.
PROCEDURE 32: OLD SUGGESTED SCHEDULE FOR EXAMINATION OF SERS CASES AT THE ARMED FORCES INSTITUTE OF PATHOLOGY. REMOVED 4/99.
PROCEDURE 33: QUALITY CONTROL IN THE HISTOLOGY LABORATORY.
PROCEDURE 34: STAINING QUALITY IN HISTOLOGY.
PROCEDURE 35: QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY.
PROCEDURE 36: INFECTION CONTROL POLICY.
PROCEDURE 37: SAFETY PROCEDURES FOR CONTAMINATED SPECIMENS.
PROCEDURE 38: POLICY FOR RETENTION OF MATERIALS.
PROCEDURE 39: HISTOLOGY LABORATORY ROUTINE MAINTENANCE.
PROCEDURE 40: MAINTENANCE OF CRYOSTAT.
PROCEDURE 41: DAILY CHECKLIST FOR FROZEN SECTION AREA.
PROCEDURE 42: OLD WEEKLY CHECKLIST FOR FROZEN SECTION SERVICE. REMOVED 4/99.
PROCEDURE 43: STORAGE OF LABORATORY REAGENTS.
PROCEDURE 44: EQUIPMENT MONITOR FORMS.
PROCEDURE 45: DAILY MAINTENANCE CARE IN-USE PROCESSOR (HISTOMATIC).
PROCEDURE 46: INSTRUCTIONS FOR POLARIZED LIGHT MICROSCOPY.
PROCEDURE 47: CASE HELD AND TISSUE STAINING REQUEST.
PROCEDURE 48: TISSUE FIXATION.
PROCEDURE 49: ROUTINE HEMATOXYLIN AND EOSIN.
PROCEDURE 50: VAN GIESON'S METHOD FOR COLLAGEN FIBERS.
PROCEDURE 51: VERHOEFF'S ELASTIC STAIN.
PROCEDURE 52: METHODS FOR CARBOHYDRATES AND MUCOPROTEIN.
PROCEDURE 53: OLD WILDER'S METHOD FOR RETICULUM. REMOVED 4/99.
PROCEDURE 54: RETICULUM (HORTEGA'S, MODIFIED).
PROCEDURE 55: MODIFICATION OF MASSON'S TRICHROME STAIN.
PROCEDURE 56: IMMUNOHISTOCHEMICAL STAINING.
PROCEDURE 57: OLD TECHNICAL INFORMATION/DESCRIPTION OF REAGENTS. REMOVED 4/99.
PROCEDURE 58: PHOSPHATE BUFFERED SALINE pH 7.6.
PROCEDURE 59: DAB SUBSTRATE PREPARATION.
PROCEDURE 60: AEC SUBSTRATE PREPARATION.
PROCEDURE 61: COATING SLIDES WITH POLYLYSINE.
PROCEDURE 62: COATING SLIDES/SECTIONS AFTER CUT.
PROCEDURE 63: TRYPSIN DIGESTION.
PROCEDURE 64: PEPSIN DIGESTION PROCEDURE.
PROCEDURE 65: PHOSPHATE BUFFER PREPARATION.
PROCEDURE 66: STAINS FOR CYTOPLASMlC GRANULES.
PROCEDURE 67: MAY-GRUNWALD GIEMSA METHOD.
PROCEDURE 68: OIL RED O IN PROPYLENE GYCOL METHOD FOR FATS.
PROCEDURE 69: BENHOLD'S METHOD FOR AMYLOID (CONGO RED).
PROCEDURE 70: OLD LIEB'S METHOD FOR AMYLOlD (CRYSTAL VIOLET). REMOVED 4/99.
PROCEDURE 71: MODIFICATION OF MOWRY'S 1958 COLLOIDAL IRON STAIN FOR ACID MUCOPOLYSACCHARIDES.
PROCEDURE 72: MAYER'S MUCICARMINE STAIN.
PROCEDURE 73: POTASSIUM FERROCYANIDE-HYDROCHLORIC ACID SOLUTION.
PROCEDURE 74: HYALURONIDASE DIGESTION METHOD.
PROCEDURE 75: DIASTASE DIGESTION METHOD.
PROCEDURE 76: GOMORI'S METHOD FOR IRON.
PROCEDURE 77: METHENAMINE SILVER FOR FUNGI AND PCP.
PROCEDURE 78: BIELSCHOWSKY'S METHOD FOR AXIS CYLINDERS AND DENDRITES.
PROCEDURE 79: FITE'S METHOD FOR ACID FAST ORGANISMS.
PROCEDURE 80: ZIEHL-NEELSEN CARBOL FUCHSIN SOLUTION.
PROCEDURE 81: BROWN AND BRENN METHOD FOR GRAM POSITIVE GRAM NEGATIVE BACTERIA.
PROCEDURE 82: GROCOTT'S METHOD FOR FUNGI (GMS).
PROCEDURE 83: WARTHIN-STARRY TECHNIQUE.
PROCEDURE 84: IMMUNOPEROXIDASE STAINING.
PROCEDURE 85: PH MONITOR.
PROCEDURE 86: FROZEN SECTION STAINING SOLUTIONS MONITOR.
PROCEDURE 87: QUALITY CONTROL FOR HISTOLOGY STAINING PROCEDURES.
PROCEDURE 88: OLD CYTOLOGY PROCEDURE MANUAL (TITLE PAGE). REMOVED 10/99.
PROCEDURE 89: CYTOLOGY GENERAL INFORMATION.
PROCEDURE 90: CRITERIA FOR ACCEPTANCE OF CYTOLOGY SPECIMENS.
PROCEDURE 91: CYTOPREPARATORY CELL COLLECTION DISPLAY MODALITIES.
PROCEDURE 92: CENTRIFUGATION.
PROCEDURE 93: FILTERING OF STAINING SOLUTIONS.
PROCEDURE 94: OLD ACETO-ORCEIN WITH FAST GREEN FOR BARR BODY DETERMINATION. REMOVED 4/99.
PROCEDURE 95: ALCOHOLS.
PROCEDURE 96: INCONCLUSIVE URINE CYTOLOGIES.
PROCEDURE 97: 10% GLACIAL ACETIC ACID & CYTO-LYT SOLUTION.
PROCEDURE 98: OLD STAINING SCHEDULES. REMOVED 11/97.
PROCEDURE 99: OLD FINE NEEDLE ASPIRATION STAINING PROGRAM. REMOVED 11/97.
PROCEDURE 100: PAPANICOLAOU STAIN FOR ROUTINE MEDICAL AND GYNECOLOGIC CYTOLOGIES.
PROCEDURE 101: DIFF-QUIK STAIN PROCESS.
PROCEDURE 102: DESTAINING TECHNIQUE.
PROCEDURE 103: RESTAINING AND RECOVERING.
PROCEDURE 104: FEMALE GENITAL TRACT.
PROCEDURE 105: INSTRUCTIONS FOR PROCESSING ALL NON-GYNECOLOGIC SPECIMENS.
PROCEDURE 106: BODY FLUIDS PLEURAL, PERITONEAL.
PROCEDURE 107: NON-MUCOID SPECIMENS: URINE, CSF, SYNOVIAL FLUIDS.
PROCEDURE 108: MUCOID SPECIMENS: BRONCHIAL WASHINGS, LAVAGE, SPUTUM.
PROCEDURE 109: SPECIMENS WITH BRUSHES.
PROCEDURE 110: THIN-PREP PROCESSOR FIGURES.
PROCEDURE 111: CYTOBLOCK PREPARATION FOR TISSUE FRAGMENTS FROM CYTOLOGY SPECIMENS.
PROCEDURE 112: CYTOPATHOLOGY LABORATORY QUALITY CONTROL.
PROCEDURE 113: QUALITY IMPROVEMENT PROGRAM IN CYTOPATHOLOGY.
PROCEDURE 114: PROCEDURE FOR LABORATORY HANDLING OF UNIDENTIFIED, UNSATISFACTORY AND MISLABELED SPECIMENS.
PROCEDURE 115: SAFETY PRECAUTIONS IN CYTOPATHOLOGY.
PROCEDURE 116: STORAGE OF LABORATORY REAGENTS AND DISPOSAL OF FLEX-100.
PROCEDURE 117: LABORATORY MAINTENANCE RECORDS.
PROCEDURE 118: PROCEDURES FOR CLEANING DIRTY REUSABLE LABORATORY UTENSILS AND DISPOSING OF CONTAMINATED SPECIMEN CONTAINERS AND UNUSED SPECIMENS.
PROCEDURE 119: STAT LABORATORY PROCEDURES FOR CYTOLOGY SPECIMENS COLLECTED AFTER REGULAR LABORATORY WORKING HOURS.
PROCEDURE 120: PROCEDURES FOR ACCIDENTAL NEEDLE STICK OR MUCOUS MEMBRANE EXPOSURE TO BLOOD OR SECRETIONS/EXCRETIONS FROM INFECTIOUS PATIENTS.
PROCEDURE 121: PROCEDURES FOR HANDLING, PROCESSING AND DISPOSING OF ALL INFECTIOUS CYTOLOGY MATERIALS.
PROCEDURE 122: VISTA COMPUTER SYSTEM (FORMERLY DHCP).
PROCEDURE 123: GUIDELINES FOR CIRCULATING SLIDES, TISSUE BLOCKS AND REPORTS: GUIDELINES FOR CIRCULATING SLIDES TO IN-HOUSE STAFF.
PROCEDURE 124: ANNUAL REVIEW OF PROCEDURES.
PROCEDURE 125: ANNUAL STATEMENT OF KNOWLEDGE OF PROCEDURES.
PROCEDURE 127: OLD ACETO-ORCEIN WITH FAST GREEN FOR BARR BODY DETERMINATION. REMOVED 4/99.
PROCEDURE 128: POLICY FOR PROTECTING AND PRESERVING SLIDES IN ANATOMIC PATHOLOGY.
PROCEDURE 129: 1991 BETHESDA SYSTEM.
PROCEDURE 130: POLICY FOR TUBERCULOSIS EXPOSURE CONTROL.
PROCEDURE 131: AEROSPRAY CYTOLOGY STAINING SYSTEM.
PROCEDURE 132: SHANDON VARISTAIN XY HISTOLOGY SYSTEM.
PROCEDURE 133: CYTOLOGY LABORATORY EQUIPMENT MAINTENANCE.
PROCEDURE 134: MAIN OBJECTIVES OF CYTOLOGY LABORATORY.
PROCEDURE 135: PREPARATION AND MAINTENANCE OF CYTOLOGY STAINS AND SOLUTIONS.
PROCEDURE 136: CYTOLOGY SPECIMEN HANDLING OF HIGHLY INFECTIOUS CASES.
PROCEDURE 137: INTERDEPARTMENTAL CONSULTATIONS.
PROCEDURE 138: INVASIVE PROCEDURES REVIEW COMMITTEE.
PROCEDURE 139: THINPREP PROCESSOR OPERATING INSTRUCTIONS.



QUALITY IMPROVEMENT IN ANATOMIC PATHOLOGY (Procedure 35)
Jules J. Berman, PhD, MD.


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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.



STEP-BY-STEP DESCRIPTION.

      1. QUARTERLY QUALITY ASSESSMENT IN ANATOMLC PATHOLOGY BY AFIP. Unknown cases distributed by the AFIP are discussed at the 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 of 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.

      3. PEER REVIEW LN SURGICAL PATHOLOGY.
      a. All microscopic tissue examinations of surgical tissue are performed by a staff pathologist and all surgical tissue diagnoses are made by a staff pathologist.

      b. 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. An attendance record is kept. Unresolved differences of opinion are recorded and can be sent to an outside consultant for review (usually the AFIP or NIH).

      c. 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, who issues a lateness monitor.


      4. MONITORS. All reports are reviewed, signed, and released, by electronic signature to the VISTA Computer System. Simple 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. Dr. Moore presents pathology findings each month at the IPRC, and these findings become part of the official IPRC minutes.

      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 two 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:
      a. Notification of a new positive (for cancer) diagnosis, with the exception of basal cell carcinoma of skin.

      b. Notification of unsatisfactory specimens (new for 1998 CAP inspection).


      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
 P-30121 .......... TUMOR BOARD PRESENTATION


      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. Our department has more than 5 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, the 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; (4) in a continuing education program contracted by the VA for Quality Assessment in anatomic pathology and administered by the Armed Forces Institute of Pathology (AFIP); and (5) in the U.S. Government contract for the autopsy pathology Apex program (College of American Pathologists).

      9. 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.

      10. PROTOCOL FOR HANDLING DISPARITIES OR ERRORS IN DIAGNOSIS, INCLUDING SURGICAL, CYTOLOGY AND FROZEN SECTION SPECIMENS. Significant disparities require the following steps:
      a. The final report must specify the disparity.

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

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

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

      e. The disparity must be documented in the monthly pathology monitor submitted to the Chief, Pathology and Laboratory Medicine.


      11. 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 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 by Dr. Kao, dermatopathology consultant, who concurs," or "This case was reviewed by Dr. Kao, dermatopathology consultant, 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."

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

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

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

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

      e. 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.

      f. 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.

      g. Consultation cases are all SNOMED-coded (the consultation code is 3005) and can be retrieved at any time via SNOMED-search.




REFERENCES.

      1. Bonfiglio TA, Somark TM.
ASCP Educational and Proficiency Testing Programs in Cytopathology.
Lab Med. 1994;25:245-247.
      2. Borkowski A, Lee DH, Sydnor DL, Johnson RJ, Rabinovitch A, Moore GW.
Intranet-Based Quality Improvement Documentation at the Veterans Affairs Maryland Health Care System.
Mod Pathol. 2001;14:1-5.
Full Text of Article.
      3. Moore GW, Berman JJ.
Anatomic Pathology Data Mining.
Chapter 4. In: Cios KJ, ed. Medical Data Mining and Knowledge Discovery. Berlin/Heidelberg: Springer Verlag. 2000.
Full Text of Article.



AUTHOR AND EFFECTIVE DATE.


Date last revised:

Signature and date approved:

Chief, Pathology and Laboratory Medicine Service (113)

Chief, Anatomic Pathology Section

Supervisor, Histology and Cytology

Last Updated: 5/17/2001, by G. William Moore, MD, PhD.