[1657] A Taxonomy of Amended Reports Assesses Impact of Henry Ford Production Sysytem [HFPS] a Lean Quality Initiative in Surgical Pathology

FA Meier, RC Varney, R D'Angelo, A Gandhi, RJ Zarbo. Henry Ford Hospital, Detroit, MI

Background: Amendments change previously issued surgical pathology reports, to cause re-work, confusion, distrust. In 2002-2005 we developed and validated a taxonomy of defects using amendments. Since 2005, this classification has provided information about HFPS LEAN initiatives for eliminating defects in surgical pathology.The objective is to use real-time, ongoing identification, classification, and root cause analysis to study defects causing amended reports and to assess effects of LEAN process improvements on patient and specimen identification, specimen adequacy, diagnostic interpretation, and report generation by applying our validated, standard taxonomy.
Design: For 2006, 2007, and through August 2008, we identified all amended reports, gathered systematically information about them in real time, classified using the taxonomy, determined root causes, and used this information to inform interventions. HFPS LEAN initiative included, goal-directed education of clinicians identifying patients, specimens, redesign of specimen accession, and introduction of double reading (internal, pre-sign-out review) of all breast and prostate cases. During these interventions we recorded: total amended reports, amendments/1000 surgical reports, and fractions of defective reports due to mis-interpretation, mis-identification, specimen defects, and report defects.
Results: Total amendments deceased from 374 on 2006 to 306 in 2007 to 261 (annualized) in 2008: an overall reduction of 18%. This was reflected in yearly amendments/1000 reports rates decreasing from 7. 8 to 6.3 to 5.5 (annualized). Misinterpretation fraction declined from 16% to 7% to 2% of defects: an overall 8-fold decrease. Mis-IDs remained at 12% in 2006 and 2007, but appear to have more than halved, to 5%, in 2008. Specimen defects, 4% in 2006, rose to 11% in 2007, and reduced to 3% in 2008. Because of these reductions, report defects now account in 2008 for 90% of defects, after accounting for 68% and 70% in 2006 and 2007.
Conclusions: Although undetected confounding factors cannot be excluded in real practice situations, it appears that focused double review, of a relatively small faction of cases [800/47,500 (2%)], has had a high return in decreased misinterpretations. By our measures, the return from goal-directed clinician education on misidentification has been modest, and accession redesign has not shown an effect on these indices of quality. Overall, however, the impact of HFPS LEAN has been to drive down amendments.
Category: Quality Assurance

Monday, March 9, 2009 1:00 PM

Poster Session II # 243, Monday Afternoon