Histopathology National QI

Programme – Annual Workshop

10 May 2016

Histopathology National QI

Programme – Introduction & Update

Dr Niall Swan, Chair Histopathology QI Programme Working

Group

10 May 2016

Vision of National QI Programme

A patient centred Quality Improvement framework within each department, which facilitates their

routine review of performance and drives improvement, in key quality areas against

intelligent targets.

Development Stage of Programme

Initiation

Engagement

Stakeholders

Design:

Guidelines

Data Collection –LIS

Data Recording

NQAIS

Roll-out

Conducting

Recording

Reporting on NQAIS

Measure

Data analysis

Target Setting Methodology

Control

Targets set

4

Framework set up :•Guidelines•Quality Data Collection•Quality Data Reporting•Intelligent Targets set

Radiology programme39 Sites collecting Quality Data

GI Endoscopy34 sites collecting & recording data on NQAIS

Histopathology programme32 sites - public & private conducting, collecting & reporting on NQAIS

08/06/2016

Wisdom hierarchy

WISDOM

KNOWLEDGE

INFORMATION

DATA

Ongoing Stage of ProgrammeReview by units of their own data on a regular

basis against intelligent targets and appropriate

learning and actions

Annual review of Guidelines, documents,

Indicators, intelligent targets, support for

quality improvement and learning

Quality Improvement by units and shared learning

6

•Relevant national framework •Specialists can review their own data and act •Opportunity to share learning on improvements•Improved patient care

Histopathology programme32 sites public and private conducting, collecting and reporting on NQAIS

08/06/2016

Current Status of Histopathology Programme• 32 labs conducting quality activity and recording data

• First data report only included 15 labs

• Targets set for 22 out of 50 key quality indicators (minimum 12 months data required)

• National Aggregate Data Reports 2014, 2015 & 2016

• What the hospital sees?• Laboratory

• Hospital management

• What the programme sees?

• What difference has it made?

• Challenges

• Opportunities e.g. RCQPS research collaborative, improvements, publications…

Data improvements• The timeliness, volume and accuracy of data is improving

– see compliance slides.

• Completion of Memorandums of Understanding by hospital management seems to support departments overall.

• Sharing of reports and data in context outside laboratories with Clinical Directors, hospital management, etc– increases profile of histopathology

– facilitates further quality improvement.

• Help to share learning through the programme and hospital groups

– Areas for development

– Areas of best practice

Cancer centre (C) submission rates – 6 May 2016

= Uploaded months

= new uploads since last Steering Committee Compliance Report

= not applicable/Hospital inactive

= Upload requested for Dec 15

= months behind

Overall status – improved

32 sites

8 private, 28 public– Including 8 cancer centers.

All have uploaded December data, 28 have uploaded January data.

Remaining sites have been reminded & are working through issues.

23 sites have also uploaded February 2016 data, which was due on

the 1st May.

centertype

Oct

2014

Nov

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Mar

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Apr

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May

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Upload

statusMonths

behind

cc3 new upload 2M 1

cc7 new upload 1M 0

cc4 new upload 1M 1

cc1 new upload 1M 0

cc5 new upload 1M 0

cc6 new upload 2M 0

cc2 new upload 1M 1

cc8 new upload 1M 0

Total arrears in months (all labs combined) 3

General centre (NC) Submission rates – 6 May 2016

centertype

Oct

2014

Nov

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Dec

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Jan

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Feb

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Mar

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Apr

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May

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Jun

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Jul

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Aug

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Sep

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Oct

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Nov

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Dec

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Jan

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Feb

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Mar

2016Upload status

Months

behind

nc1 new upload 1M 0

nc2 new upload 2M 0

nc3 new upload 2M 0

nc4 new upload 3M 0

nc5 new upload 2M 0

nc6 new upload 1M 0

nc7 new upload 2M 1

nc8 new upload 2M 0

nc9 new upload 1M 1

nc10 new upload 2M 0

nc11 new upload 1M 0

nc12 new upload 1M 0

nc13 new upload 2M 0

nc14 2

nc16 1

nc17 new upload 2M 0

nc18 new upload 1M 0

nc19 new upload 1M 0

nc20 new upload 1M 0

nc21 new upload 1M 1

nc22 new upload 1M 0

nc23 2

nc24 2

nc25 new upload 2M 0

Total arrears in months (all labs combined) 10

Summary of Histopathology GuidelinesKey Quality Area (Monitor) Key Quality Indicators #, measure

Workload Total no of cases

1a Inter-institutional consultation – Cases referred externally for review 2: % Cases referred, % Agreement

1b Inter-institutional consultation – Received internally for review 2: % Cases received, % Agreement

1c Inter-institutional consultation – Cases referred externally for opinion 1: % Agreement

2 Intradepartmental Consultation 3: 3-5 % Cases for Histo & Cyto FNA, 7-9% Cyto Exfoliative,

3 Frozen Section Correlation 3: 97% Concordance, 5% Deferral rate >10% needs review

4 Frozen Section TAT 85% TAT < 20 minutes

5 Cytological/histological correlation 3: % Discordant, % False positive, % False negative

6a Retrospective review (Focused real time) 1: % Agreement

6b Retrospective review (report completeness)

1: % Completeness (POS approach – cancers of Endometrium & pancreas)

7 Multi disciplinary Team meetings - By P-Code 2: % Agreement, % of total cases discussed - By P-Code

8 Non-conformance reporting 2: No. of non-conformances, Clinical impact

9 External Quality Assessment 2: List of Schemes, results

1108/06/2016Blue – potential target/recommendation

Dark red – Quality Improvement activityYellow – discussing today

Green – targets set

Summary of Histopathology GuidelinesKey Quality Area (Monitor) Key Quality Indicators #, measure

10 Turnaround Time (TAT)

6 areas 1 indicator: TAT by case type 80% day 5 i. P01 Small Biopsy ii. P02 GI Endoscopic Biopsy

80% day 7 Non Biopsy iii. P03 Cancer resection, P04 Other

80% day 5 Non gynae cytology – v. P06 FNA vi.P07 Exfoliative

11 Addendum Reports 3: Quantity, Error classification, Clinical impact

12 Critical Diagnosis/Value reporting 1: No. of cases reported directly to clinician (audit in progress)

13 Adult Autopsy – Intradepartmental Consultation 1: 2% all cases

14 Adult autopsy case review 1: % of total cases reviewed

15 Adult autopsy turnaround time 1: TAT by autopsy case type

16 Paediatric Autopsy extra departmental

consultation

1: % of total cases reviewed at M&M

17 Paediatric autopsy retrospective review 1: % of total cases reviewed

18 Paediatric turnaround Time 1: TAT by paediatric turnaround time

19 Quality / Discrepancy Meetings participation Possible addition – learning opportunities

1208/06/2016

Blue – potential target/recommendation

Dark red – Quality Improvement activityYellow – discussing today

Green – targets set

Targets setSet Monitor Target & Key Indicators

Round 1

Round 2Intradepartmental

Consultation

3- 5 % All Cases (round 1)

3-5% Histo cases (retain)

3-5% Cytology Exfoliative (retain)

7- 9% Cytology FNA

Round 1

Round 2Frozen Section 97% Concordance

5 % Deferral rate, >10% <1% needs review,

85% TAT < 20 minutes

Round 1 Turn around Time TAT by case type

i. P01 Small Biopsy – 80% day 5

ii. P02 GI Endoscopic Biopsy – 80% day 5

iii. P03 Non Biopsy – Cancer resection – 80% day 7

iv. P04 Non Biopsy – Other – 80% day 7

v. P06 Non gynae cytology – FNA – 80% day 5

vi. P07 Non gynae cytology - Exfoliative – 80% day 5

Round 2 Intradepartmental

Consultation

2% Adult Autopsy All cases

10/02/2015 13

QA to QI – Lloyd Provost

Ref: ‘The Health Care Data Guide, learning from data for improvement’. Lloyd P. Provost & Sandra Murray. Jossey Bass

• Group 1 follows rounds 1 and 2 methodology where measures are

defined and data is appropriate for national target setting.

• Group 2 includes quality areas where definitions are agreed but no

national data has been collected. Future targets are settable but only

when sufficient data is available for review. A minimum of 12 months data

will be collected.

• Group 3 comprises quality areas where the type of data being recorded

is not applicable for national target setting as agreed definitions for these

KQIs are not currently achievable. A recommendation only is being

suggested for local quality improvement activity.

• Group 4 consists of quality areas where insufficient national data is being

collected through the QI programme. Some of these quality areas are

captured through other routes e.g. INAB and EQA. The updated

guidelines will reflect this.

• Group 5 sets out new key quality areas following refinement of initial

measure and maturing of the data. Recommended codes will be

circulated and data collected prior to any potential target setting.

08/06/2016 18

Clinical Governance – Oversight proposal

National developments - 2015• Award winning – Excellence in

Healthcare Management (from 18)

• L – R: Sarah Treleaven RCPI, Maureen Flynn

HSE QID, Philip Ryan RCPI, Dr Jennifer Martin

HSE QID ( Steering Committee Chair), Prof

Conor O’Keane Faculty of Pathology, Dr Ann

O’Shaughnessy RCPI, Dr Niall Swan

Faculty of Pathology (Working Group Chair).

Missing from photo, Dr Julie McCarthy, Dr Sine Phelan, Prof Kieran Sheahan, Dr Ann

Treacy (Working Group members) Mairead Guinan RCPI Programme Manager

• Memorandum of Understanding with participating hospitals

• Health Information and Patient Safety Bill – due for publication in

2017

1. Employ more effective teamwork in the diagnostic

process (DP)

2. Enhance healthcare professional education and

training in the DP

3. Ensure health IT supports patients & HCP in the DP

4. Develop and deploy approaches to identify, learn

from, and reduce diagnostic errors and near misses

in clinical practice

5. Establish a work system and culture that supports

the diagnostic process and improvements in

diagnostic performance

6. Develop a reporting environment and medical

liability system that facilitates improved diagnosis

through learning from diagnostic errors and near

misses

7. Design a payment system and care delivery

environment that supports the DP

8. Provide dedicated funding for research on the DP

and diagnostic errors

8 Goals from

Institute of Medicine

Communications• Presentations - International

– “Implementation of a national patient-centred clinician-led Histopathology National

Quality Improvement (QI) Programme to enhance patient care and safety”, March

2015, Grand Rounds, Dept of Pathology & Laboratory Medicine, Boston Medical

Centre & Boston University School of Medicine, USA

– “Jurisdictional Quality plans & indicators in Interpretative Pathology: experience in

Canada and abroad: Implementation of a national patient-centred clinician-led

Histopathology National Quality Improvement (QI) Programme to enhance patient

care and safety”, Canadian Laboratory Medicine Congress (CLMC), Canadian

Association of Pathologists, CAP-ACP Annual Meeting Jun 2015

– “An Innovative System for Histopathology Quality Improvement / Assurance”, Jun

2015 Meeting, UEMS Specialist Section of Pathology, European Pathology Board

– “Set up and Implementation of a Patient-centred Clinician-led Histopathology

National Quality Improvement (QI) Programme” Pathsoc/BDIAP joint meeting, Jun

2015

– “Dissemination, stakeholder engagement and endorsement – the Irish Experience”

Quality Initiative in Interpretive Pathology (QIIP) Meeting, Canada Jun 2015

– “Metric development & implementation for a patient-centred clinician-led

Histopathology National Quality Improvement (QI) Programme”, QIIP Workshop

Communications• Presentations - National

– “Implementation of a patient-centred clinician-led National

Quality Assurance (QA) Programme in Histopathology to

enhance patient care and safety”, National Patient Safety

Conference, Dublin November 2014 (12 selected from 1,07l

abstracts) submitted

– “Histopathology Quality Improvement Programme – an update”,

Radiology QI Programme Annual Workshop, June 2015

– “Specialty Quality Improvement Programmes, current status and

future developments”, Clinical Directors Masterclass, September

2015

Communications• Posters - National

– “Implementation of a patient-centred clinician-led Histopathology

National QI Programme”, National Office of Clinical Audit, Inaugural

Annual Conference, Dublin, May 2015

– “Implementation of a patient-centred clinician-led National QI

Programme in Histopathology”, Irish Society of Surgical Pathology,

Kildare, October 2015

• Posters - International

– “Implementing a National Quality Assurance Programme in

Histopathology”, USCAP, Seattle, USA, March 2016

– “Impact of Intradepartmental Consultation on Amended Report Rate:

Findings from the Irish National Quality Improvement Programme in

Histopathology”, USCAP, Seattle, USA, March 2016

– “Communication with Clinicians in Anatomical Pathology”, USCAP,

Seattle, USA, March 2016

International developments – 2015/2016

• Maintaining programme in Ireland is top priority.

• Ireland remains a world leader, as the only country to

collect this data nationally across public and private

sector.

• Other countries very interested in the Irish approach

– Canada, QIIP review in 2016

– Presentation of three posters at USCAP meetings over past 3

years

– BDIAP / Path Soc (8th Joint Meeting) - differing approach in the

UK- individual poor performance focus on EQA schemes

– UEMS - Opportunities for consultation with Hungary and

Germany

Opportunities for participating sites

• RCQPS – research collaborative HSE QID /HRB / RCPI,

opportunity to access funds fore research relating to quality

and patient safety.

• Up to €280,000 over 2 years.

• Research question – link with academic researchers,

competitive rounds of funding, submit May, final decision

Sept.

• Think about topics – next round May 2017.

• Current topic is LEAN via Bill Bennett –

‘Can LEAN Six Sigma Methodology be used to develop

integrated software tools to improve patient care in surgical

pathology?’

Opportunities for participating sites

• Clinical audit – easy access to information

via NQAIS

• Build up CME points

• Use your data in more detail – publications

• Application – Team ,Diploma in Healthcare

Management & Quality Improvement (link)

• National data – Prof Sheahan

AcknowledgementsProgramme Team: Ms. Mairéad Guinan, Mr. Philip

Ryan, Ms Sarah Treleaven,

Working Group: Dr. Julie McCarthy, Prof J. Conor

O’Keane, Dr Sine Phelan, Prof. Kieran Sheahan,

Dr Ann Treacy

Dr. Jennifer Martin - HSE QID (current funder)

Mr. Seamus Butler & Mr. Brian Dunne - HSE OCIO

Mr. Mel McIntyre & Mr. Pawel Starawz - OpenApp

Dr. Howard Johnson HSE HII,

Dr. Mary Hynes – NCCP (initial funder),

Mr. Leo Kearns & Ms. Louise Casey - RCPI