QUALITY MANAGEMENT PLAN FOR SURGICAL PATHOLOGY-ALL ADVOCATE SITES What it is, why we need it, what references were used, what it entails, why it will be helpful, what extra work this will entail, and whom to blame!

Questions? Arguments?

• Please read the plan and the attachments • Please contact me or the member of your department who participated in creating the plan with your concerns.

From the CAP Surgical Pathology Checklist • ANP.10000 Phase II N/A YES NO • • Is the quality management program defined and documented for surgical pathology?

NOTE: The type of program may vary depending upon factors such as number of staff and workload.

QUALITY MANAGEMENT PLAN FOR SURGICAL PATHOLOGY-ALL ADVOCATE HEALTHCARE HOSPITAL SITES •

Note: This plan serves as a guideline for Quality Assurance in Surgical Pathology at all Advocate Healthcare Hospital Sites. Based on the size of each hospital, the scope of service at each hospital, the number of cases at each hospital, the number of Pathologists at each hospital, an individual hospital department may elect to perform Quality Assurance monitors more frequently than specified. Based on whether or not a department utilizes Pathology Assistants, additional policies and procedures regarding such individuals are available at the individual sites.

• • • • • • • • • Who worked on the plan (i.e., whom to blame) Asya Ali Imad Almanaseer Stephanie Appelbaum Carey August Pat Kampmeier Sanobar Khan Oliver Kim Tom McCaffrey Jami Walloch

GOALS

• • To ensure Quality To standardize Quality Management across all sites

GOALS

• • • • To have plans defined and documented for all aspects of Anatomic Pathology by Jan 1, 2011 To incorporate responses to as many CAP Checklist items as possible To facilitate reporting of departmental quality measures and quality measures for individual pathologists To make collection of data and mining of data as painless as possible

Departmental QM vs. PI for Individual Pathologists • • Departmental QM: monitors which are measures of what the department achieves as a whole, reported to PI, thresholds of acceptability Individual Pathologist PI: evaluations using the determinations of OFI and NOFI, part of the Medical Director’s recredentialing information and Peer Review

OFI and NOFI

OFI and NOFI Advocate Systemwide Policy 90.17.42

• •

OFI

Opportunity for Practitioner Improvement “Deviation of Clinical Care from Medical Standards” • •

NOFI

No Opportunity for Practitioner Improvement “No deviation of Clinical Care from Medical Standards”

References

• • • • • CAP Checklist Recommendations of the Association of Directors of Anatomic and Surgical Pathology Articles from Pathology literature Advocate Healthcare Systemwide Policy 90.017.042, “Medical Staff Peer Review Process” Additional help: Carol Mathera, Dr. William Werner (AIMMC’s Vice President for Clinical Transformation)

Elements of The Plan-four categories • • • • Preanalytic Analytic Postanalytic Turnaround time

Preanalytic

• • Elements of the plan which necessitate a QM Monitor: Adequacy of Specimen Submission and Labeling; Lost Specimens Elements of the plan which are included only to define a policy: Cases Submitted from Outside Institutions and some parts of Adequacy of Specimen Submission and Labeling

Adequacy of Specimen Submission and Labeling • • • Enumeration of elements of unacceptable specimens and how they are handled Record of “Specimen Discrepancy” cases via CoPath Retrieval Flag On a semiannual basis, the Medical Director at each site will review all cases with the Specimen Discrepancy Retrieval Flag to identify trends

Lost specimens

• • • • • Definition from ADASP Threshold for lost specimens: 1/3000 cases Additional qualifications for the definition of “lost”: this will NOT include specimens that often yield no tissue such as ECC Record of “Lost Specimen” cases via CoPath Retrieval Flag Annual review by Medical Director

Analytic

• Elements of the plan which necessitate QM +/- Peer Review monitors: On-going Evaluation of Quality of Histology,Enrollment in Peer Education Programs, Surg Path/NonGyn and FNA Cytopath Correlation, Accuracy of Intraoperative Consultations,Extradepartmental Opinions • Elements of the plan which are included only to define policies: Intradepartmental Consultations, Extradepartmental Consultations Sought by Departmental Pathologist and Ancillary Studies,Gross Examinations by Prosectors, including Pathologist, Pathology Residents, Pathology Assistants, and Pathology Assistant Trainees,Specimens Exempted from Microscopic Examination

Analytic-Elements Which Necessitate a Monitor • • • • • On-going Evaluation of Quality of Histology Enrollment in Peer Educational Program Correlation of Current Cases with Previous Surgical Pathology and Nongynecologic Cytopathology Cases Accuracy of Intraoperative Consultations Extradepartmental Opinions

On-going Evaluation of Quality of Histology (CAP ANP.11713) • • Enter “Slide Quality” comments in CoPath as you are working Weekly report prepared for each site using “Slide Quality” Retrieval Flag, sent to ACL Histology Manager, ACL AP Manager, Medical Director of Histology

Enrollment in Peer Education Program • • • • Each site’s Pathologists are all ready enrolled in a Peer Education Program (CAP or ASCP) Medical Director monitors results annually Acceptable threshold for each department as a whole: 90% “correct” answers OFI: Individual Pathologist chooses fewer than 90% of the “correct” answers in cases where more than 50% of participants choose the “correct” answer

Correlation with Previous Nongynecologic Cytopathology • • • On-going review at the time of sign-out Peer Review monitor only: Quarterly review by Medical Director of CoPath report listing which lists each Surgical Pathology case for which there is either Nongynecologic or FNA Cytopathology case within the prior 60 working days OFI: Cyto -/SP + or vice versa; review of Cyto shows Pathologist missed or misinterpreted findings which were present

Accuracy of Intraoperative Consultations • • • Quarterly review by Medical Director at each site of CoPath “Intraoperative Diagnosis vs. Final Diagnosis” report Acceptable threshold for each department as a whole: 95% of cases with no discrepancy OFI situations: Intraop/Final Dx discordant AND there is a significant effect on intraop patient management Intraop/Final Dx discordant AND the discrepancy was NOT due to sampling, no matter whether or not there was effect on intraop patient management

• • • • Extradepartmental Opinions (opinions sought by patient or clinician) On-going follow-up of cases leaving the department; generation of Addenda as needed Use of additional expert consultation and ancillary testing as needed Quarterly review by Medical Director at each site; threshold for cases without clinically significant discrepancies = 90% OFI: Departmental and extradepartmental diagnoses are discordant AND clinically significant AND extradepartmental consultant did not have any additional information or follow-up that may have been unavailable to the departmental pathologist

Postanalytic

• • Elements of the plan which necessitate a QM monitor-Use of Synoptic Reports in Cancer Cases Elements of the plan which are included only to define a policy: Critical Values, Record Retention

Use of Synoptic Reports in Cancer Cases • • • • SNOMED search of cancer cases performed for January, February, and March of each year Medical Director reviews 30 cases requiring Synoptic reporting (or the entire three months’ worth if less than 30 cases) Threshold for department as a whole: 90% of cases requiring Synoptic report have one OFI: Pathologist completes Synoptic report in less than 90% of cases requiring Synoptic report

Turnaround Time

• • • Two elements of the plan, both requiring monitors Frozen Section Turnaround Time Surgical Pathology Turnaround Time

Frozen Section Turnaround Time

• • • • Definition of Turnaround Time: Interval between time specimen arrives in the laboratory and time Frozen Section is reported Pathologists to record times Quarterly review by Medical Director at each site: Expected TAT is 20 minutes or less in 90% of cases which do not have multiple blocks or multiple specimen parts received simultaneously OFI: individual Pathologist does not meet this standard

Surgical Pathology Turnaround Time • • • • Definition of Turnaround Time: Accesion to Sign-out CAP: “Routine” cases-2 working day TAT Quarterly review by Medical Director at each site using the CoPath “Specimen Turnaround Time by Pathologist” report; threshold: 80% of all cases complete within 2 working days OFI: individual Pathologist does not meet this standard

Goals

• • How are we doing?

We can review how well the Quality Management Plan meets each goal on a scale of one to five

Define and Document Quality Management Plan by Jan 1, 2011

To standardize the Quality Management Plan across all sites

To incorporate responses to as many CAP Checklist items as possible

To facilitate reporting of data

To make collection and mining of data as painless as possible