Documentation of Quality Assurance Activities in Surgical Pathology: 5-Year Experience Post Introduction of a Comprehensive Quality Assurance Program.
Michael Sidiropoulos, Mahmoud A Khalifa, Corwyn Rowsell. Sunnybrook Health Sciences Centre, Toronto, ON, Canada
Background: A comprehensive quality assurance (QA) program can greatly enhance the quality and efficiency of the surgical pathology laboratory by documenting processes, identifying discrepancies, and ultimately illuminating areas for potential improvement. The success of such programs, however, is largely dependent upon participation by departmental staff. A comprehensive QA program with quarterly reporting of QA activities was introduced in our department in 2006. We performed an audit of our overall QA program from 2006-2010 to document changes in QA participation.
Design: QA data in surgical pathology was collected every quarter (Q) since the second quarter of 2006. The following parameters were tracked: recording of intraoperative consultation (IOC) vs final diagnosis correlation, prospective reviews, retrospective reviews, and total QA activities documented in surgical pathology. In addition, total amended reports and turnaround time (TAT) measures were documented.
Results: Total QA activities recorded increased from 8% in Q2 2006 to 15% in Q2 2010. This was largely due to the increase in recording of prospective reviews from 3% to 8% over the same period. There was no significant change in retrospective reviews (range 1- 3%). Total recording of IOC vs final correlation by pathologists was 96% in Q2 2006, rose to a high of 99% in Q4 2006, had a low of 83% in Q3 2008, and rose to 100% in Q2 2010.
Total amended reports decreased from 0.93% in Q2 2006 to 0.53% in Q2 2010. Overall TAT remained consistent over the study period ranging from 4-6 days; however improvements were seen in number of cases signed out within 48 hours (21% in Q2 2006; 33% in Q2 2010).
Conclusions: After the introduction of a comprehensive QA program in surgical pathology, we have seen a significant increase in documentation of QA activities over a five-year period. Factors which may have played a role in the increase include introduction of prospective review policies for targeted specimens and monthly reminders to pathologists to record QA activities. Our experience illustrates that creating a learning, non-punitive environment focussing on patient safety rather than "errors" encouraged pathologists to report their review results and comply with QA guidelines.
Category: Quality Assurance
Monday, February 28, 2011 1:00 PM
Poster Session II # 216, Monday Afternoon