Transcript QUALITY MANAGEMENT PLANS FOR ANATOMIC PATHOLOGY

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Quality Management Plan for Surgical
Pathology and NonGynecologic Cytopathology
Quality Management Plan for Autopsy
Pathology
Attachments A-L
You must be kidding.
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Read the Quality Management Plan for
Surgical Pathology and NonGynecologic
Cytopathology
Read the Quality Management Plan for
Autopsy Pathology
Read Attachment E and Attachment L
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Botttom line information regarding your daily
contribution to collecting data
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Procedure for creating “QA-Slide Quality”
Retrieval Flag in CoPath
Specimen
Case #
Final Dx Entry/Edit
Staff
Retrieval Flag
From dropdown, select, “QA-Slide Quality”
Enter comment (e.g., “too thick”, “mislabeled”, etc)
OK
Save/Next Specimen
No action and “Yes”
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Weekly report of problems in Histology quality
will be generated, sent to Medical Director of
Histology, AP Manager, Histology Manager
Real time documentation of problems in
Histology quality
Obviates the need to complete a Histology
evaluation every day
Satisfies CAP Checklist requirement for
feedback to Histology Laboratory
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Medical Directors
Pathologists in charge of Anatomic Pathology
Quality Management
Pathologists who oversee Histology and
Clerical Staff
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Templates for monitor reporting
List of cases requiring second pathologist review
Frozen section TAT data collection form
List of monitors to be performed, frequency of
reporting, type of monitor (QM vs Peer Review)
List of CoPath reports, frequency, recipient
Responsibility of Clerical Assistant at each site for
cases sent to extradepartmental pathologist
Resonsibility of Histology personnel at each site
for Specimen Discrepancy and Lost Specimen info
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Incorporation of all feedback received
Extraneous monitoring removed
CAP checklist items referenced in text of plans
Modification of OFI’s
How did we fix them?
Have fun!
Remember her name
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List of specimens that the HOSPITAL may
choose to exclude from routine submission to
Pathology
Details of qualifications, supervision, and
evalutions of PA’s
Policy about ESO-who signs your reports if
you aren’t there to do it.
Everything relating to ER/PR and Her2