Transcript HIDDEN DANGER IN PATHOLOGY - CAP-ACP

Dr. Raymond Maung
Chair (Workload & Workforce Committee)

Standard of care
 Reports
 Technology
 “onomics”
▪ Diagnostic
▪ Prognosis
▪ Therapeutics
▪ Individual and family management

Quality Assurance


Procurement to Sign-out
Current standards






Immunohistochemistry
Cytogenetics
FISH, CISH
Flowcytometry
Ploidy studies
“onomics”
 proteinomics
 transcriptnomics
 genomics


“Time for QA be considered when
determining the number of pathologists and
oncologists required for each institution so
that physicians do not have to choose
between day-to-day tasks and participation
in QA process.”
“Pathologists and oncologist should be
required to participate in such (QA) rounds as
a condition of continued employment with
the regional health authority”


“The problem arose because there was no
quality assurance protocol in place for the
laboratory and consequently, no operative
standard quality control mechanisms.”
Recommended a number of QA processes as
per national and international pathology
organizations.

“All pathologists working in Windsor adopt
the Quality Assurance Program for Pathology
developed by the Chief of Pathology which
includes peer assessments, auditing and
correlational analysis. Appropriate laboratory
physician and administrative resources
should be allocated to support the Program.”

“Foregoing participation in quality assurance
activities should not be considered an
acceptable option by pathologists or
employers - quality assurance of their work is
a mandatory requirement for pathologists
and it is one of their core elements of
responsibility for ensuring effective patient
care.”

DO NOT control our workload volume
 determined by users of laboratory services
 Most pathologists are on salary or contract with NO
clause in their contract regarding appropriate
workload

DO NOT have inherent limiting factor on
workload
 Others: OR availability, office hours, CT time
availability
 Rate limiting factor in pathology is the pathologist
ability to sign out the case

We are our own worse enemy
 In most departments, all the work processed is distributed
to the pathologists
 Most of us feel obligated to complete the work when it
lands on our desks – thus no dysfunction (wait time or
patient complaints)
 IMAGINE if there were “wait times” in pathology
▪ patients waiting 4 weeks for breast or prostate biopsy results
▪ patient informed 6 weeks after the biopsy that he has melanoma or
colonic carcinoma
▪ oncologic management is delayed due to incomplete pathology
consult
 Most patients do not know that “pathologist” exist until
there is dysfunction.




Administration understands only “dysfunction”
Without obvious visible dysfunction in
pathology, resources flow to more visible
dysfunctions, namely to shorten wait time
Attention only when “dysfunction” occurs –
various commissions in the recent past.
Laboratory and Pathology though essential for
final diagnosis, follow up and management –
most including most physicians do not know
what a pathologist really does.
Indicators of Quality and Safety
1. an increase in turnaround time;
2. not always completing QA;
3. quality compromises;
4. patient care compromised; and
5. health and well being of
pathologists being compromised
=>1
=>2
=>3
None
=>4
Dr. Matthew B. Weinger (Director, Center for Research & Innovation
in Systems Safety)
1. A rare, but very salient signal has to be detected:
desmoplastic melanoma
2. Multitasking and prioritization are key elements of
work: work disrupted by technologists or clinicians
3. There is a time gap between when information
becomes available and when it has to be used:
relevant clinical information not available when
reviewing slides.
4. Creative thought is required: when facing a lesion
unfamiliar


Studies show that working overtime or
working more than 40 hours in a week was
associated with a statistically significant
increase in the risk of making an error.
working more than 40 hours per week
(overtime), working extended shifts (more
than 8 hours), and working both extended
shifts and overtime can have adverse effects
on worker health.


Physicians are also noticed to have
deterioration in cognitive performance with
long shifts.
Accident rates increases with the length of
work , with accident rates rising after 9 hours,
doubling after 12 consecutive hours, and
tripling by 16 consecutive hours of work.


Study on 34 pediatric residents showed that
following a night of heavy call was quite similar
to performance after drinking alcohol. Reaction
times were slowed, errors of commission
increased 40%, and on simulated driving test,
lane variability and speed were significantly
increased after a night of heavy call
Interns made 35.9% more serious medical errors
during the traditional schedule (extended hours
and every third night call) than during the
intervention schedule (restricted schedule that
reduced work shifts to 16 hours).


Meta-analysis of 21 studies showed that there is
a link between hours of work and ill health, and
that working long hours can be detrimental to
health of an individual and his/her family.
Analysis of 27 empirical studies showed that
long work hours were associated with adverse
health effects (cardiovascular disease, diabetes
mellitus, disability retirement, physiological
changes, and health-related behavior).
Two significant nuclear power plant accidents (Three
Mile Island and Chernobyl) and the environmentally
disastrous grounding of an oil tanker (Exxon Valdez)
occurred at night, during early morning hours when
vigilance is at its lowest.
 Fatigue-related problems are believed to cost the
United States an estimated $18 billion dollars per year
in lost productivity and accidents. More than 1,500
fatalities, 100,000 crashes, and 76,000 injuries
annually are attributed to fatigue-related drowsiness
on the highway.

1998
2008
% change
Family Physician
1,060
994
+6.2%
Medical specialists
1,635
1,529
+6.5%
Surgical specialists
3,912
4,048
-4%
Lab. Physicians
21,311
21,686
-1.8%
Pathologists
27,612
27,991
-1.4%
All physicians
538
512
+4.8%
Population / per lab. physician
Population / per pathologist
1998
2008
% change
1998
2008
% change
Saskatchewan
19943
26251
-31.6%
Saskatchewan
23653
31024
-31.2%
BC
18498
19644
-6.2%
BC
22322
23636
-5.9%
Ontario
23744
24784
-4.4%
Ontario
27587
28418
-3.0%
Quebec
18276
18753
-2.6%
Quebec
33844
37237
-10%
Canada
27612
27991
-1.4%
Newfoundland
16769
16967
-1.2%
Canada
21311
21686
-1.8%
1998
2008
% change
Saskatchewan
29
41.5
-43%
Newfoundland
27.9
36
-29%
BC
34.7
39.3
-13.30%
Alberta
38.7
43.7
-12.90%
Quebec
37.6
40.1
-6.60%
Ontario
41.5
43
-3.90%
New Brunswick
40.1
40.3
-0.50%
Canada
38.5
41.4
-7.50%



high portion of departments were
understaffed (74%, varies from -11 % to -66.67%)
In BC, the government insisted on a workload
volume 18.75% and in Quebec 67.46% higher
than the recommended L4E value.
Recently there were 3 major and many minor
“mishaps” in pathology throughout Canada.
Population /provider
Australia (pathologist)
17,829
Canada (Lab.Phy.)
21,686
Canada (pathologist)
27,991
US (pathologist)
19,231

CAP-ACP has
updated the
Workload model

 a (all): Gross +Micro in surgicals,
unscreened slides in cytology
 m (micro): Micro only in
surgicals, screened slides in
cytology
 s (special): Consults, Reviews,
Special studies, Correlations,
etc.
 e (education): Working with
trainees
 includes QA
activities
 Simplified so that
learning 9 rules will
allow to code for
most specimens
 Academia
▪ Education & training
▪ Scholarly work
(research)
 Administration
Model flexible to meet the
needs for most departments

Spreadsheet to implement the
model available
Comparable to other models
Comprehensive: includes QA activities, academia and
administration
 Flexible: from community to academic centers
 Fair


 Public: provides efficient and effective pathology services
 Funding agencies: the recommended workload is higher
than other models and integrates QA work as
recommended by various commissions and agencies
 Providers: provides a safe workload enabling to produce
best pathology services for clinicians and the public


Endorsed by CAP-ACP
“Living” document with input from pathologists
throughout Canada
 Extensive experience

ONE CANADIAN MODEL will
 Allows for comparison between departments and
provinces
 Allow pathologists to negotiate with Heath
Authorities more effectively – workload
 As QA activities are built into the model, essential QA
activities will be recognized (as recommended by the
commissions) as part of the workload
“given that medical personnel, like all human
beings, probably function suboptimally when
fatigued, efforts to reduce fatigue and
sleepiness should be undertaken, and the
burden of proof should be in the hands of the
advocates of the current system to
demonstrate that it is safe.”


Questions ?
Comments ?