J Clin Pathol 1991;44:10-16 Audit in histopathology: Description of an internal quality assessment scheme with analysis of preliminary results J A Zuk, W E Kenyon, M W Myskow Abstract In the first six months of a formal Internal Quality Assessment Scheme operating in the Department of Histo- pathology, Broadgreen Hospital, Liver- pool, 1005 items of data were gathered, relating to 80 cases. The scheme entails a random 2% sample of biopsy specimens being selected, each case being analysed using a structured proforma, and a numerical scoring system being allocated to all aspects of specimen handling. Technical and secretarial per- formance was good while the quality of clinical information provided by the requesting clinician was poor. There was a wide variation in reporting times, which related partly to the complexity of the specimen, and partly to the degree of supervision required by the reporting pathologist. Month by month analysis of reporting times showed a significant increase in reporting times associated with rotation of junior staff, but not with periods of annual leave. Pathologist per- formance scores were good, but close examination of components of the overall score for an individual path- ologist indicated occasional areas of weakness (such as the adequacy of the macroscopic report). It is concluded that this scheme is worthwhile and its practice will be con- tinued indefinitely. The comprehensive nature of the analysis allows for the for- mal identification of areas of work which need improvement, and the allocation of a formal numerical score allows improvement in these areas to be mon- itored. The monthly meetings provide a means whereby performance scores are fed back to the participating path- ologists, and they are also of general educational value regarding histological reporting practice. It is intended that the scheme be extended to include the assessment of special stains, frozen sec- tions, and adequacy of the report delivery service. The system is easily adaptable for use within other histopath- ology departments. It is vital that high standards of histopath- ology reporting are achieved and maintained, with appropriate measures being introduced towards improvement where required. The report entered into the patient's notes is still widely held to be of "gold standard" and often includes the primary diagnosis on which patient management depends.' External Quality Assessment Schemes (EQAS) contribute towards the maintenance of standards, but such schemes have been introduced relatively slowly into histopath- ology compared with other disciplines, although one which assesses technical performance in immunohistochemistry has existed for some time.2 Such EQAS are also of educational value and help towards uniformity and consistency of reporting. The requirement for maintenance of the quality of our services has been recently reinforced by proposals for the reorganisation of the NHS,' which will create a more competitive atmos- phere and will also emphasise the need for all doctors to participate in medical audit.4 EQAS arguably evaluate the maximal potential standard which any participating laboratory or individual is capable of reach- ing, much like the situation of an examination. This contrasts with internal quality control (or assessment) which is concerned with frequent, regular review of all laboratory procedures.' It examines what is actually happening within these departments under normal functional circumstances. Because many histopathology departments include junior medical staff, it could be anticipated that the maintenance of standards of various aspects of a pathologist's work, in particular surgical reporting, is likely to prove difficult to achieve. Furthermore as is clearly stated in the recently published Royal College of Path- ologist's Code of Practice for Pathology Departments, the responsibility for the main- tenance of standards of all aspects of work lies with the head of the department.5 We therefore decided to introduce an Inter- nal Quality Assessment Scheme (IQAS) to evaluate and monitor the quality of all aspects of work in our department, with emphasis on the performance of the histopathologist. As well as having other benefits, we hoped our scheme would highlight any deficiencies within our service which would be amenable to change and improvement, this being a major criterion of effective medical audit.6 Scheme design THE DEPARTMENT Our Scheme was devised and developed to meet the particular needs of the Histopath- Department of Histopathology, Broadgreen Hospital, Thomas Drive, Liverpool L14 3LB J A Zuk W E Kenyon M W Myskow Correspondence to: Dr Myskow Accepted for publication 29 August 1990 10 on January 8, 2022 by guest. Protected by copyright. http://jcp.bmj.com/ J Clin Pathol: first published as 10.1136/jcp.44.1.10 on 1 January 1991. Downloaded from
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J Clin Pathol 1991;44:10-16
Audit in histopathology: Description of aninternal quality assessment scheme with analysisof preliminary results
J A Zuk, W E Kenyon, MW Myskow
AbstractIn the first six months of a formalInternal Quality Assessment Schemeoperating in the Department of Histo-pathology, Broadgreen Hospital, Liver-pool, 1005 items of data were gathered,relating to 80 cases. The scheme entails arandom 2% sample of biopsy specimensbeing selected, each case being analysedusing a structured proforma, and anumerical scoring system beingallocated to all aspects of specimenhandling. Technical and secretarial per-formance was good while the quality ofclinical information provided by therequesting clinician was poor. There wasa wide variation in reporting times,which related partly to the complexity ofthe specimen, and partly to the degree ofsupervision required by the reportingpathologist. Month by month analysis ofreporting times showed a significantincrease in reporting times associatedwith rotation of junior staff, but not withperiods of annual leave. Pathologist per-formance scores were good, but closeexamination of components of theoverall score for an individual path-ologist indicated occasional areas ofweakness (such as the adequacy of themacroscopic report).
It is concluded that this scheme isworthwhile and its practice will be con-tinued indefinitely. The comprehensivenature of the analysis allows for the for-mal identification of areas of work whichneed improvement, and the allocation ofa formal numerical score allowsimprovement in these areas to be mon-itored. The monthly meetings provide ameans whereby performance scores arefed back to the participating path-ologists, and they are also of generaleducational value regarding histologicalreporting practice. It is intended that thescheme be extended to include theassessment of special stains, frozen sec-tions, and adequacy of the reportdelivery service. The system is easilyadaptable for use within other histopath-ology departments.
It is vital that high standards of histopath-ology reporting are achieved and maintained,with appropriate measures being introducedtowards improvement where required. The
report entered into the patient's notes is stillwidely held to be of "gold standard" andoften includes the primary diagnosis on whichpatient management depends.'
External Quality Assessment Schemes(EQAS) contribute towards the maintenanceof standards, but such schemes have beenintroduced relatively slowly into histopath-ology compared with other disciplines,although one which assesses technicalperformance in immunohistochemistry hasexisted for some time.2 Such EQAS are alsoof educational value and help towardsuniformity and consistency of reporting. Therequirement for maintenance of the quality ofour services has been recently reinforced byproposals for the reorganisation of the NHS,'which will create a more competitive atmos-phere and will also emphasise the need for alldoctors to participate in medical audit.4EQAS arguably evaluate the maximal
potential standard which any participatinglaboratory or individual is capable of reach-ing, much like the situation of an examination.This contrasts with internal quality control(or assessment) which is concerned withfrequent, regular review of all laboratoryprocedures.' It examines what is actuallyhappening within these departments undernormal functional circumstances. Becausemany histopathology departments includejunior medical staff, it could be anticipatedthat the maintenance of standards of variousaspects of a pathologist's work, in particularsurgical reporting, is likely to prove difficultto achieve. Furthermore as is clearly stated inthe recently published Royal College of Path-ologist's Code of Practice for PathologyDepartments, the responsibility for the main-tenance of standards of all aspects of work lieswith the head of the department.5We therefore decided to introduce an Inter-
nal Quality Assessment Scheme (IQAS) toevaluate and monitor the quality of all aspectsof work in our department, with emphasis onthe performance of the histopathologist. Aswell as having other benefits, we hoped ourscheme would highlight any deficiencieswithin our service which would be amenableto change and improvement, this being amajor criterion of effective medical audit.6
Scheme designTHE DEPARTMENTOur Scheme was devised and developed tomeet the particular needs of the Histopath-
Department ofHistopathology,Broadgreen Hospital,Thomas Drive,Liverpool L14 3LBJ A ZukW E KenyonMW MyskowCorrespondence to:Dr MyskowAccepted for publication29 August 1990
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Assessment of Requesting Consultant(a) Consultant's name(b) Request Form - clerical details complete/accurate 1
incomplete ± inaccurate 0- clinical details good 2
adequate 1incomplete/absent 0
11 Technical Performance- section quality good 1
adequate 0poor/inadequate -1
- staining quality good 1adequate 0poor/inadequate 1
III Pathologist PerformanceSpecimen type -Specimen category: 1/2/3 (biopsy/resection)(a) Times taken (ignore Sat, Sun and public holidays) Time Satisfactory/
Unsatisfactory
(i) Request date to Rep. Approved(ii) To Pathologist (1 st time) until to typist(iii) To typist to date and time typed(iv) From typist to Rep. Approved
(if Rep. Approved after 16.30 h count as next day)
designated teaching hospital and district gen-eral hospital for East Liverpool, with a work-load for the year ending March 1989 of 7800requests. Medical staffing consists of two con-sultants and usually one each of senior houseofficer, registrar, and senior registrar (all jun-iors except SHO rotate to other hospitals).
All aspects of work are fully computerised,the system having been developed and pilotedat this site and designed to run in conjunctionwith the McDonnell Douglas Patient Informa-tion System (Homer; McDonnell Douglas,Hemel Hempstead, England). On receipt,individual specimens are categorised asfollows: urgent, taken out of main stream andhandled individually (category I); priority,inpatient diagnostic biopsies (category II);routine, all others (category III). For analysispurposes, category III is divided into biopsyspecimens and resections. Categorisation wasintroduced to take account of the fact thatspecimen types I and II are those on whichimmediate patient management decisions are
most frequently made.
ASSESSMENT SCHEME
Operating regularly since July 1989, this con-
sists of a monthly retrospective analysis of a
random 2% of surgical cases. These are selec-ted from the month falling six weeks before theassessment date, and each month is con-
secutively analysed. The figure of 2% wasconsidered to be high enough to be represen-tative while still being a compromise betweenthe detail of our analysis and the practicality ofits implementation in view of the timerequired.A nominated person (usually the senior
registrar) coordinates the Scheme, organisescase selection and retrieval of all materialrelevant to each case, including histologicalsections, the report, and a computer printout ofitemised data concerned principally with therecorded times of key events involved in reportgeneration as follows:(a) request date (REQ)(b) date and time slides first presented to
pathologist (TO PATH)(c) date and time report presented for typing
(TO TYPE)(d) date and time report typed (TYPED)(e) date and time final report is signed and
approved by pathologist (REP APPR).Cases are then distributed to one of several
possible auditors, these being pathologistsfrom within our department not involved withthe case being reviewed and who had at leastextensive post-primary MRCPath experience.An assessment checklist (figure) for completionaccompanies each case. Fourteen variables areindividually scored, the scheme emphasisinganalysis of pathologist performance (ninevariables, three conceming key times in report
(c) Report(i) Clerical details - including specimen
(comparing to original request form) correct 1incorrect minor 0(e.g. wrong Cons/source)Incorrect major 1(wrong name/dob/unit no)
(ii) SNOMEDCorrect 1Incorrect 0
(iii) Final DiagnosisAgree 1Partially disagree 0(not serious)Serious disagreement 1
(iv) Macro clarity and Content
Adequate 1Inadequate 0Serious Omission 1Not applicable x
generation) but also assessing performance ofrequesting clinician (clerical and clinical detailssupplied), MLSOs (section and stainingquality), and typists.
All aspects of the pathologist's routine dailyperformance in diagnostic histopathology are
scored from initial macroscopic descriptionand block selection to clarity and content ofmicroscopic report, together with final diag-nosis reached, accuracy of SNOMED usage,
and accuracy of patient clerical details on finalsigned report. Scores are weighted to accountfor the magnitude and seriousness of omissionsor errors. Total scores are calculated, themaximum being 7, although for some
specimens this is reduced if the assessmentcategories of block selection and macroscopicdescription are not applicable.
Several key time intervals are also calculatedfrom computer data and recorded (with one daydeducted for each Saturday, Sunday, andpublic holiday). Any action recorded as havingoccurred later than 16.30 h was regarded as
having happened first thing next morning, as16.30 h is the deadline for delivery of com-
pleted reports from our office.Auditors are given seven to 10 days to
complete their assessment after which allmedical staffmeet to discuss the cases, allowingfor direct feedback of performance which takesabout an hour a month. Information relating totechnical and clerical performance is presentedto laboratory staff immediately afterwards, as
required.
Preliminary resultsThe following is an analysis of preliminaryresults obtained from the first six months ofourScheme. One thousand and five items of dataderived from 80 cases were analysed. A similaranalysis will be performed on a regular sixmonthly basis. Specimen categories were asfollows: category I (one case); category II (10cases); category III (69 cases). For purposes ofanalysis, category III was divided into biopsyspecimens (n = 44) and resections (n = 25).Student's t test was used for statistical analyses.
REQUESTING CLINICIAN
Specimens were received from 27 individualsources. The overall average score for clinicaldetails supplied was 67 5% (averages forindividual sources ranging 25-100%). Clinicaldetails were good in 50% of cases, adequate in35%, and inadequate or absent in 15%.For clerical details, the average score for all
27 sources was 81% (ranging from 50-100%for each individual). This information was
incomplete or inaccurate in 19% of cases.
TECHNICAL PERFORMANCE
In 79 cases there was sufficient material toassess quality of histological sections, with an
average score of 78%, section quality beingassessed as good (81% of cases), adequate(16%), and poor (3%). Fifteen cases were thusdetermined to be of suboptimal quality for thefollowing reasons: "holes" (n= 5); folds (n = 5);debris (n=2); "chatters" (n= 1); "scores"(n = 1); and absence of full transverse section
Table 1 Total specimen scores obtained (expressed inpercentages)
Average Range ofscore (whole averagesforgroup of individual
Specimen type pathologists) pathologists
All specimens (80) 87 80-91Category I (1) 100 -
Category II (10) 92 85-100Category III (44) (biopsy) 87 82-96Category III (25) (resection) 84 76-97
(n = 1). Suboptimal sections were from 10% ofcategory II specimens, 14% of category III(biopsy), and 36% of category III (resection)specimens, this reflecting the nature of tissuecut and larger blocks numbers derived fromresections.
Quality of staining (haematoxylin and eosinand special stains) was evaluated in 66 cases(omitted in first, pilot month of study), with anaverage score of 92%. Quality was assessed asonly adequate in 8% and poor in a further 2%of cases. Monthly variability for section andstaining quality was 62-92% and 79-100%respectively. There was quite random monthlyfluctuation-that is, there was no obviouschange in performance as the scheme evolved.
PATHOLOGIST PERFORMANCEThe 80 cases were reported by seven path-ologists-two consultants, one senior registrar,three registrars and one SHO, the registrarnumbers reflecting the rotation of junior staff.Of the 63 cases reported by juniors, 40 of 44diagnoses reached and reports issued by SHOand registrars, and two of 19 cases reported bythe senior registrar were under direct consul-tant supervision. The remaining 9% of casesreported by SHO and registrars were undersenior registrar supervision. Macroscopic des-cription and block selection were almost alwaysunsupervised.
(i) Pathologist scoresThe overall average total scores for the group ofseven pathologists with ranges of averagescores for individuals are detailed in table 1.There is a general trend between scores andspecimen type with better average performancefor priority specimens (categories I and II), butthis was insignificant (statistics not applicableto category I as only one case). Greatest inter-individual variability in performance was forcategory III (resection) specimens. For all data
Table 2 Scoresfor individual variables ofpathologistperformance (expressed in percentages)
Range ofNumber of Average averagecases score scoresforto which (all individual
Variable analysed this applies pathologists) pathologists
relating to performance, only one serious errorwas found ("serious omission" for macroscopicdescription of category III resectionspecimen). More detailed analysis of theindividual variables ofpathologist performancewhich contribute to the final report was perfor-med (table 2) in an attempt to identify specificareas ofweakness. Despite the range of averageindividual scores for a final diagnosis of 67-100%, there was never any serious dis-agreement from the diagnosis stated, and evenminor deviation from excellence was downmarked as we consider this to be the mostimportant part of the entire report.A wide range of average scores for individual
pathologists was found for microscopic clarityand content (range of 28%) and even more sofor macroscopic clarity and content (range of67%). The latter accounts for the wide range ofaverage individual pathologists' scores forcategory III resection specimens (table 1), anarea obviously requiring improvement.Accuracy of SNOMED categorisation also
shows substantial interindividual variability(table 2) which may reflect junior staff's lack offamiliarity with the system. The figures forclerical detail check clearly indicate unneces-sary individual carelessness at the vital stage offinal report checking before signing.
Variables of pathologist performanceapplicable to all specimen categories were fur-ther analysed according to category (table 3).There exists an obvious trend between averagescores for microscopic clarity and content and
Table 4 Time intervals between request date and date and time of report approval(expressed in days)
Average Range ofSpecimen type for all averages for all Absolute(number of specimens) pathologists pathologists Mode range
All (80) 4 0 3-3-44 3 1-10Category I (1) 10 - - -Category II (10) 2-6 2 2-3 0 2 2-4Category III (44)
Table S Time interval (TO PATH/TO TYPE) (expressed in days)
Range ofAverage averages forfor all individual
Specimen type pathologists pathologists Mode Range
All 1 7 10-2-5 1 0-7Category I 0 - -
Category II 1 3 0-0-2-0 1 0-3Category III biopsy 1.5 10-2-1 1 0-4Category III resection 2 1 1 2-40 1, 3 0-7
*NB Only one specimen in category I.
specimen type, with a lower average score forresections compared with category III biopsyspecimens (not significant; 05 < p < 0 1)compared with category II specimens. Possiblerelevant factors accounting for this includelonger report length of microscopic report forresections and the fact that all staff are acutelyaware of the prime importance of category IIspecimen reports.For all specimen types, average scores for
diagnosis were quite consistent and high.SNOMED and clerical detail check errors wereslightly more common for category IIspecimens, which may reflect the introductionoferrors as the pathologist attempts to expeditethese important reports.
(ii) Pathologist reporting timesThe figures presented in table 4 concern thetotal time interval between the time a request ismade and the time that report is completed andapproved by the pathologist. This shows a wideabsolute range (one to 10 days) for allspecimens and is at best a very crude indicatorofperformance as it is subject to many variablesbeyond the pathologist's control (fixation,processing, and especially specimen delivery).As expected, shorter times were found forhigher priority specimens. We provide aservice for our own hospital and for twoperipheral hospitals and general practitioners,with an average of 3-7 days (request date toreport approved) for specimens from withinour own hospital and 4-3 days for all othersources.The calculated time interval, which is a
direct measure of pathologist performance, isthat time interval between when sections arefirst presented until the time the written his-tology report is presented for typing (TOPATH/TO TYPE) (table 5). Again there is anobvious trend, with more rapid reporting ofhigher priority specimens (categories I and II)and for category III biopsy specimens (notsignificant) as would be anticipated, as this wasthe reason for the initial introduction ofspecimen categorisation. Although these seemexcessive-for example, category II-average13 days-as previously stated, any actionoccurring after 16.30 h was recorded as havingoccurred the following day, and many reportsare submitted for typing after this deadline.Our average figures for all pathologists for
the reporting interval TO PATH/TO TYPEare interpreted as satisfactory. For eachspecimen type, however, there exists con-siderable interindividual variation for this cal-culated interval. At all times report qualityremained top priority, and we endeavour tostrike a balance between quality and speed.Fifty seven per cent of all cases were reportedby juniors under direct supervision and theeffect ofsuch supervision on the reporting timeTO PATH/TO TYPE was therefore furtheranalysed (table 6). For supervised andunsupervised specimens there was a generalcorrelation between specimen priority andspeed of reporting, in terms of both averagetime and mode. We interpret the necessarydelay introduced in reporting category III
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(biopsy and resection) specimens as reasonable,but find the approximate doubling of thisaverage time interval for category II specimensunacceptable. All three supervisors performedsimilarly with little interindividual variabilityin average scores and reporting times for thespecimens they supervised.
(iii) Effect of stage of studyFor each month ofthe study, the average scoresfor all pathologists for all specimens, sub-divided according to specimen type, arepresented in table 7. The monthly variabilityfor average scores was 75-94% for allspecimens (80-100% for category II, 81-94%for category III (biopsy) and 71-100% forcategory III (resections). We interpret this as areasonable degree of variability, and there wasno obvious trend between scores in anyspecimen category and month of study, exceptthat all scores tended to be low for the first(pilot) month of study (May 1989). Since ourscheme was introduced in July 1989, it suggeststhat it has proved beneficial to pathologistperformance, but this requires further study.The average monthly pathologist reporting
times (TO PATH/TO TYPE), subdividedaccording to specimen category, are shownin table 8. For all specimens together, themonthly variability was 1-3-2-2 days (category
Table 8 Average monthly specimen reporting times (TO PATH/TO TYPE)according to specimen type (expressed in days)
Average reporting time
All Category III Category IIIMonth of study specimens Category II biopsy resection
II 0-2 days, category III biopsy specimen 1 1-1 8 days, and category III resection specimen1-2-4-3 days). Longest average reporting timeswere in the month of October, being accountedfor by category II (average of two days) and inparticular category III resection specimens(4-3 days). This coincided with our acquisitionof two new junior pathologists in Octoberwhich may account for this observed reportdelay. Confirmation of this explanation willdepend on an analysis of future trends.The average of 2-0 days for category II
specimens during October 1989 is unaccepta-bly high, requiring a change in practice, aroundthe time of rotation of new Registrars into theDepartment each October. Note, however, thatscores for performance (table 7) were main-tained during this period.
TYPIST PERFORMANCEOne of the major factors determining finaltimes of report generation from any depart-ment is typist performance (table 9). We inter-pret our typists' performance as beingexcellent, with 86% of all reports typed before16.30 h on the same day the pathologist's reportis presented to them. All priority specimens aretyped the same day, which necessarilyintroduces delay for the other specimen types.
PERFORMANCE OF AUDITORSFinally, in an attempt to confirm the validity ofour assessment and scoring system, the mark-ing performance of all four auditors wasstudied (table 10). As in any marking system,subjective interindividual variation in scoringwill be found. Greatest degrees of suchvariability were found for the assessment of thefollowing: clinical information supplied; stain-ing quality; macroscopic description; and useof SNOMED. This variability reflects, at leastpartly, personal preferences of individualauditors. During our monthly audit meetings,however, discussion is aimed at encouragingreasonable uniformity in the assessments madeby the auditors.There was little interindividual variability in
the marking of variables of final diagnosis(range of 16%), macroscopic clarity and con-tent (13%), and clerical information check.Because we regard these as the most importantqualitative aspects of all reports issued and asthese key variables of pathologist performancewere marked quite consistently, we concludethat our assessment and scoring system isindeed valid.
DiscussionWe introduced our -IQAS as a method ofmedical audit whereby we could assess,monitor, and evaluate the histopathologyservice we provide. Our process covers theperformance of pathologists, technicians,typists and the clinicians initiating requests. Itis therefore in some ways similar to a systemalready described,7 but differs in the greaterdepth of analysis undertaken in our scheme.Our system fulfills the major principles of
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All specimens 86 14Category II 100. 0Category III biopsy 86 14Category III resection 80 20
the process of effective audit8 in that it isrelevant, objective, quantified and repeatablewith formal identification of areas requiringimprovement. It also provides a method forreassessment of performance once appropriatechanges have been implemented. As with allvalid audit systems, this final step of reassess-
ment is of utmost importance, resulting in the"closing of the audit feedback loop".6 Weintend performing the monthly assessmentprocess as routine on an indefinite basis, withstatistical analysis of all data accumulated over
each six monthly period, as we illustrate here.We have no doubt that the introduction of
our IQAS has been a worthwhile activity withits benefits greatly outweighing its main dis-advantage, which is the use of valuable time.Because all activities within the department are
being monitored, this in itself is a majorincentive towards optimal performance by allconcerned. With slight modification thescheme is adaptable for use within otherhistopathology departments, and alreadyothers from within our region have expressedinterest.Our study has provided verification that, in
our opinion, most pathologists' activities in ourdepartment are performed satisfactorily interms of both accuracy and speed. The systemhas allowed for the formal identification of theneed for improvement and action required incertain areas of work. Our monthly meetingsprovide a means whereby there is directfeedback of these faults to the appropriatepathologist. Specifically, we have identifiedimportant individual weaknesses in clarity andcontent of the microscopic report, and even
more so in macroscopic description ofresectionspecimens. Appropriate action requiredincludes further education and closer super-
vision, as well as making individuals aware oftheir particular weaknesses. We have alsoidentified unnecessary carelessness by certainpeople in the use of SNOMED coding and,even more importantly, clerical detail check-ing, especially for category II (priority biopsy)
specimens. Alerting the pathologists to theseparticular faults should in itself result inimprovement. The speed of completion ofsupervised category II reports, particularly attimes of acquisition of new junior staff,requires improvement, and supervisors are
now well aware of the need for more rapid andpunctual supervision. Reanalysis of futureresults will enable us to check thatimprovement has occurred in the correct direc-tions.As well as highlighting faults, our monthly
meeting is of general educational value, oftenleading to wider discussion of certain issues. Ithelps towards uniformity and consistency ofreporting, which is important with junior staffrotating through the department. The pos-sibility of introducing set reporting formats formost specimen types has been raised, theseformats being written guidelines which wouldact as a check to ensure that all necessarypositive and negative points are included in a
report, but without completely abolishingindividual style.One of the major findings of this study has
been the formal identification of poor perfor-mance of certain clinicians, in terms of bothclerical and clinical details supplied on requestforms. As well as being potentially dangerous,such practice wastes the time of clerical staffand pathologists. About one fifth of all requestshad inaccurate or absent clerical details, butthis practice is by no means restricted to our
hospital.9 As always, it lies with the pathologistto educate clinicians in the dangers of this andwe intend presenting the actual figures at our
hospital "grand round" on a six monthly basis.Letters stating the need for improvement couldalso be sent to poor performers.
In future we intend to maintain the same
general format of our IQAS, but our system isnot intended to be static. In addition to ourcurrent practice, we will also undertake thefollowing:
(i) A retrospective analysis of performanceduring the six months before the intro-duction ofour scheme to establish whetherits implementation has resulted in im-provement.
(ii) Extensive assessment of performance ofreporting category I (high priority)specimens (as only one was included in thissurvey); assessment of frozen sections.
(iii) Assessment of reporting a randomly selec-ted proportion of cases from each bodyregion, systematically and consecutively.
(iv) Analysis of the use of further work by thepathologist (special stains, immunohisto-
Table 10 Performance of auditors
Variable scored
Requesting consultant MLSOs Pathologist
Clerical Clinical Section StainTotal InformationInformation Total Quality Quality Total Micro Macro Diagnosis SNOMED Clerical Blocks
Range of averagescores given byauditors 62-77 80-88 50-76 75-92 72-86 75-100 83-91 73-86 58-91 84-100 80-100 88-100 83-100
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chemistry, etc,) in terms of its contributionto final diagnosis and effect on reportingtimes.
(v) Monitoring our delivery services, both toand from our department, especially as one
of the major findings of the Royal Collegeof Pathologists' pilot scheme in laboratoryaccreditation was delay in the report des-patch for no good reason.9
1 Lee FD. External quality assessment in histopathology: anoverview. J Clin Pathol 1989;42:1009-1 1.
3 Department of Health. Working for Patients. London:HMSO, 1989.
4 Department of Health. Working for Patients. Medical audit(working paper No 6). London: HMSO, 1989.
5 Royal College of Pathologists. Codes ofpracticefor pathologydepartments. London: RCP, 1989:7.
6 Smith T. Medical audit. Br Med J 1990;300:65.7 Ramsay AD, Gallagher PJ. Quality control of surgical
pathology in peer review- the Southampton experience. JPathol 1989;158:343A.
8 Shaw CD, Costain DW. Guidelines for medical audit: sevenprinciples. Br Med J 1989;299:498-9.
9 The College Accreditation Steering Committee. RoyalCollege of Pathologists' United Kingdom pilot study oflaboratory accreditation. J Clin Pathol 1990;43:89-91.
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