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Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and Ageing
Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
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Table of Contents
Executive Summary ...................................................................................................... 3 General Findings from the Integrated Analysis ....................................................................................................................................... 4 Consistent Themes Identified from the Integrated Analysis .................................................................................................................. 5 Conclusion .................................................................................................................................................................................................. 6
Abbreviations ................................................................................................................. 8
Introduction .................................................................................................................... 9 Background................................................................................................................................................................................................. 9 Terms of Reference.................................................................................................................................................................................. 10 Structure of the Document ..................................................................................................................................................................... 10
Promoting Evidence-Based Practice ...................................................................... 12 Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................... 14 Revision of Manual of Use and Interpretation of Pathology Tests (2004) .......................................................................................... 17 RCPA Manual Transformation Project (2010) ........................................................................................................................................ 18 An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ............................................................................................................... 20 Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ........................................................................................................................................................................................................ 22 A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................... 25 Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003) ........................................... 27 Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ......................................................................................................................................................................................... 30 A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................................................................................... 34 Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) .................................................................. 35 Common Sense Pathology (2006)........................................................................................................................................................... 38 Common Sense Pathology Publication Series (2011) ............................................................................................................................ 39 Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ........................................................ 40 Structured Pathology Reporting Standards for Cancer (2009) ............................................................................................................. 41 Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ............................................................... 42 Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) .. 43
Risk Minimisation ....................................................................................................... 46 RCPA – Quality Assurance Programs Key Indicator Project (2004) ...................................................................................................... 47 Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ............................. 51 Performance Monitoring of External Quality Assurance (Current) ...................................................................................................... 53 NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................................................................................................................... 54 Key Incident Monitoring & Management Systems (Current) ............................................................................................................... 55
Quality Assurance and Capacity – New Technology ........................................... 59 Virtual Microscope (2005) ....................................................................................................................................................................... 60 High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................................ 61 Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008)................................................................ 62 Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)....................................... 63 Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................................................ 64 PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................................................................................................... 67 Establishment of a Molecular Genetics Quality Assurance Program (Current) .................................................................................. 67 MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ....................................... 68
eHealth Capability ....................................................................................................... 70 Pathology Informatics Working Party (2003)......................................................................................................................................... 71 Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................. 73 Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................................. 74 Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004) ............................................................................................................................................................ 76 Supporting HL7 for Health Informatics Standards (2004) ..................................................................................................................... 77 A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ............................ 78 Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ............................................................................................................................. 82 Padlok On-line Pathology Ordering System (2005) ............................................................................................................................... 83 Information Extraction from Narrative Pathology Reports on Melanoma (2008) .............................................................................. 85
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Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................................................................................................ 87 Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................................. 88 Standardisation of Pathology Terminology and Units (Current) .......................................................................................................... 89
Pathology Requesting and Reporting – Requester and Consumer Focus .... 90 Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ...................................................................................... 92 AUSLAB Retest Interval Trial Project (2003) .......................................................................................................................................... 94 AUSLAB Retest Interval Project (2004) ................................................................................................................................................... 96 Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR Monitor (2003) .............................. 98
Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004) ................................... 99 Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ............................................................................................................................................................. 105 Quality Use of Pathology Services Education Program (2006) ........................................................................................................... 109 Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ....................................................... 111 Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) . 113 Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ....................................................................................................................................................................................... 118 Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................................................................................................. 120 The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) .. 123 Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) .................................................................................................................................................................. 124 iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) . 126 iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ......................................... 127 Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011)............................................................................... 128 Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ......................................... 133
Workforce Capacity and Competence ................................................................. 135 PathWay (2005) ..................................................................................................................................................................................... 136 The Australian Pathology Workforce Crisis (2008) .............................................................................................................................. 137 Review of Pathology Specialist Development Pathways (2010) ........................................................................................................ 143 Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................................ 147 Survey of the Pathology Workforce (2011).......................................................................................................................................... 150 Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011) .................................... 153
Consumer Focus and Information Strategies ................................................... 157 Quality Use of Pathology Consumer Consultation Project (2010) ..................................................................................................... 157 Benefits and Risks of Pathology Testing (Current) .............................................................................................................................. 159 Lab Tests Online
AU Stage 1 (Current) .................................................................................................................................................... 160
Access Initiatives – Raising Awareness .............................................................. 164 Optimising Health Benefits for Aboriginal People who take Warfarin (2009) .................................................................................. 164 Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ............................................................................................ 166 Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ............................................. 169
Communication Strategy and Stakeholder Engagement ............................... 171 Report from the National Workshop on Safety and Quality in Pathology (2007) ............................................................................ 172 The Second National Workshop on Safety and Quality in Pathology (2008) .................................................................................... 174 Best Practice in Pathology Requesting and Reporting Workshop (2009) .......................................................................................... 175 Pathology Workforce Workshop (2011)............................................................................................................................................... 177
Appendix A – Report Summaries Relevant to Different Themes................. 181
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,including
projectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresentinvestment
andcouldinformthefuturestrategicdirectionoftheprogram.ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:1. PromotingEvidence-BasedPractice2. RiskMinimisation3. QualityAssuranceandCapacity–NewTechnology4. eHealthCapability5. PathologyRequestingandReporting–RequesterandConsumerFocus6. WorkforceCapacityandCompetence7. ConsumerFocusandInformationStrategies8. AccessInitiatives–RaisingAwareness9. CommunicationStrategyandStakeholderEngagement.
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The number of reports within each theme is presented in Figure 1.
Figure 1 – Report numbers by Category
[alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachoftheninethemes’]
General Findings from the Analysis
TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice 16 10eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology 8 4WorkforceCapacityandCompetence 6 10RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies 3 4AccessInitiatives–RaisingAwareness–2outof3 3 2Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteachtheme,thenthenumberof
followoninitiativesandprojects’]
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10 12 14 16 18
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Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresultsbeing
uploadedontotheNationalElectronicHealthRecordSystemforconsumers. Standardisedrequestformsandeducationofalllevelsofhealthpractitioners
abouttheimportanceofcompletingtheinformationontheseforms. DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)
regardingevidence-basedpathologyrequesting. Investigateincludingpatient-specificadviceforGPsonpathologytestresults. FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis
Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:1. Theneedforincreasedinformationresourcesgeneratedbyreliablesources
aboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
2. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentoftheirmedicaltraining.
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3. Producingreliableconsumerinformationaboutpathologytesting,and
keepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion
TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
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Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander Medical
Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
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Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.TheprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedbyDoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:1. Quality Consumer Services:Todevelopandimproveconsumer-focused,
accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
2. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
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3. Quality Pathology Practice:Tosupportprofessionalpracticestandardsthat
meetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project
DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastandpresent
investmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report
ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
1. PromotingEvidence-BasedPractice2. RiskMinimisation3. QualityAssuranceandCapacity–NewTechnology4. eHealthCapability5. PathologyRequestingandReporting–RequesterandConsumerFocus6. WorkforceCapacityandCompetence7. ConsumerFocusandInformationStrategies8. AccessInitiatives–RaisingAwareness9. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings
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Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see
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Appendix A – Report Summaries Relevant to DifferentThemes.
Promoting Evidence-Based Practice TheQualityUseofPathologyProgram(QUPP)hasinvestigatedwaystopromoteevidence-basedpracticeofpathologythrough16projects(Table2).Whilepathology,byitsnature,isanevidence-baseddiscipline,thequalityuseofpathologyisbestservedwhendiagnosticdecisionsbytreatingpractitionersare
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alsobasedonsoundmedicalevidence.Todevisestrategiestopromotethisoutcome,existingdatabanksofpathologyorderingpatternsandtheirimpactonpatientoutcomesmustbebrokendownandanalysed,theuseoftechnologytosupportbetterdiagnosticoutcomesexploredandtheuseandawarenessofexistingresourcesandbest-practiceevidence-basedinformationtosupportdiagnosticdecisionsmustbemadeavailabletotreatingpractitioners.Medicalschoolsarealsopivotaltoevidence-basedpracticeinpathologyrequestingasnewgenerationsofmedicalpractitionersemergewithmoreinformationandresourcesavailabletoinformtheirpracticethantheirpredecessors.Thiscanalsobeahindrancetotheirpracticeasinformation‘overload’,thelackoftimetoeitheraccessordigestthisinformationandclinicalmentoringbasedonestablishedprotocols(whichmaynolongerbeinformedbybest-practiceevidence)caninfluencediagnosticandpathologyorderingdecisions.Commonissuesidentifiedthroughthisintegratedanalysisincluded: ensuringtreatingpractitionersandmedicalstudentswereawareofexisting
evidence-basedresourcesandwereutilisingthemtotheirfullcapacity incorporatinglaboratorymedicineintothecurriculumofmedicalschoolsina
meaningfulandsustainableway.Basedontheseissues,areasforfutureconsiderationtopromoteevidence-basedpracticefocusprimarilyoninformationdisseminationandstrategiestoincorporatepathologyintothecurriculumandteachingpracticesofmedicalschools.Theyinclude: Deviseastrategyto‘remind’doctorsabouttheexistenceandusefulnessof
theRoyalCollegeofPathologistsofAustralasia(RCPA)Manualatspecifiedtimeintervals.
Developguidelines/protocolsforpathologytestsforcommonconditions. Developaframeworkfordecisionsupportforgeneralpractitioners(GPs)
investigatingtirednessingeneralpracticebasedonelementsidentifiedinAProjecttoExaminetheUtilisationofPathologyTestsintheInvestigationofTirednessinGeneralPractice(2002)onpage25.
Focusonimprovingtheeducationofmedicalstudentsinundergraduatetraininginstitutions(universitiesandteachinghospitals)acrossAustraliainlaboratorymedicine.
Instigateglobalguidancebypathologistsregardingoveralldiagnostictestingstrategies,especiallyforjuniormedicalofficers(JMOs)intheformofclinicalpathwaysand/orviaaconsensualapproachwithinclinicalteamsorunits.
InvestigatetheviabilityofplacingpathologistsinhospitalwardstomentorJMOs.
Investigatetheviabilityofprovidingdetailedauditandfeedbackregardingtest-orderingpractices.
ImprovetheknowledgebaseofJMOsthroughtargetededucation. Developevidence-based,bestpracticeguidelinesfortheappropriateuseof
pathologyforGPs. CommonwealthinvestmentinNationalPrescribingService(NPS)academic
detailingstrategiesfordiagnosticservices.
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Requestereducationanddecisionsupportguidancestatements,especiallyfortheuseofthefullbloodcount(FBC),thyroidfunctiontests(TFT),multibiochemicalanalysisandliverfunctiontestsinmonitoringchronicdisease.
LiaisewithNationalHealthandMedicalResearchCouncil(NHMRC)/guidelinedevelopersregarding:
o addingan‘investigations’sectionintoguidelineso standardisingpathologyterminologyo includingpathologyrepresentationonguidelinedevelopment
workinggroups. Exploretheuseofonlinetoolsfortrainingandsupportofqualitypathology. ExplorehowtheRoyalAustralianCollegeofGeneralPractitioners(RACGP)
andtheRoyalCollegeofPathologistsofAustralasia(RCPA)canworktogethertointegrateandenhancetheutilityofthePathologyDecisionSupportTools(PDSTs)totheclinicalpracticeofrequesterssuchasanaccessiblelinktotheRCPAManualviaGP’sdesktops.
Possibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics
[alt=“ThefollowingtableliststhesixteenprojectnamesandgrantrecipientsunderthePromoting
EvidenceBasedPracticetheme”]
Project Name Grant Recipient/s
1 EvaluationoftheImpactonPathologyPracticeoftheManualofUseandInterpretationofPathologyTests(2001)
HealthcareManagementAdvisors
2
RevisionofManualofUseandInterpretationofPathologyTests(2004)
RoyalCollegeofPathologistsofAustralasia(RCPA)
3
RCPAManualTransformationProject(2010)
RCPA
4 AnHistoricalAnalysisofPathologyOrderingbyGeneralPractitionersbetweenApril1998andMarch2001fromtheBetteringtheEvaluationandCareofHealth(BEACH)Program(2002)
UniversityofSydney
5 Evidence-PracticeGapinGPPathologyTestOrdering:AComparisonofBEACHPathologyDataandRecommendedTesting(2009)
UniversityofSydney
6 AProjecttoExaminetheUtilisationofPathologyTestsintheInvestigationofTirednessinGeneralPractice(2002)
LuminisPtyLtd
7 AnalysisofCurrentPracticesinRelationtotheTeachingofPathology(LaboratoryMedicine)(2003)
HealthcareManagementAdvisors
8 AnalysisofCurrentLaboratoryMedicine(Pathology)TeachingPracticeinPrevocationalandGeneralPractitionerVocationalTraining(2003)
HealthcareManagementAdvisors
9 AMechanismfortheDevelopment,ImplementationandEvaluationofEvidence-Based,Best-PracticeClinicalGuidelinestoFacilitateQualityUseofPathologyTests(2003)
TherapeuticGuidelinesLtd
10 AcademicDetailingSupportingBetterOutcomesfromDiagnosticTechnologies(2004)
DrugandTherapeuticsInformationService(DATIS)
11 CommonSensePathology(2006) RCPA
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12 CommonSensePathologyPublicationSeries(2011) RCPA13 ImprovedPathologyReporting,EducationandPractice(IPREP)
forColorectalCancer(2009)UniversityofNSW
14 StructuredPathologyReportingStandardsforCancer(2009) CancerInstituteNSW15 PromotingandExpandingStructuredPathologyReportingof
Cancer(Stage2)(Current)RCPA
16 Evidence-Based,Best-PracticePreventionofBloodBorneVirusTransmissioninHealthCareSettingsProgram(PBBV)(2009)
SouthEasternAreaLaboratoryService(SEALS)
Table 2: Reports summarised for Promoting Evidence-Based Practice
Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001)
Description ThisprojectsoughttoevaluatetheeffectivenessoftheManualofUseandInterpretationofPathologyTestsasaresourceinAustralia.TheManualwasfirstproducedin1990bytheRoyalCollegeofPathologistsofAustralasia(RCPA)underthenewlyestablishedPathologyEducationProgram.Itsaimwastoprovideobjectiveclinicalguidancetorequestingmedicalpractitionersonthemostappropriateteststouseinthediagnosisand/ormanagementofspecificmedicalconditions.Thesecondeditionwasproducedin1997(andmadeavailableonlineviatheRCPAwebsite–http://www.rcpamanual.edu.au-in2000)andwidelydistributedtogeneralpractitioners(GPs),interns,residents,registrarsandseniormedicalstudents.AthirdeditionwasreleasedbytheRCPAviatheirwebsiteinAugust2001.
Grant Recipient HealthcareManagementAdvisors
Aims
togatherinformationastohowwidelytheManualhasbeendisseminated,andhowGPsandothermedicalpractitionersuseitinavarietyofsettings
toascertainwhyGPsmaynotusetheManualandwhethertherearemoreappropriatebutalternativemeansofassistingthemtoorderandinterpretpathologytests.
Objectives
todeterminetheextenttowhichtheManualwasdisseminatedtoGPs,interns,residents,registrarsandmedicalstudents
todeterminetowhatextentGPsareawareoftheManual todeterminethelevelofuseoftheManualingeneralpracticeandpublicand
privatehospitals todeterminehowGPsusethemanual todeterminetheextentoftheimpactoftheManualonpathologytest
selectionandtestvolume todeterminetheimpactoftheManualonpatientcareinbothmetropolitan
andruralsettings
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toestimate,wherepossible,thefinancialimpactoftheManualonMedicareandotherhealthcarecosts
todeterminewhyGPsmaynotusethemanual todiscoverwhatinformationGPsrequiretohelpthembetterorderand
interpretpathologytestsaspartofclinicalcare todiscoverhowtheinformationshouldbedisseminated.These aims and objectives were achieved by this project.
Findings Feedback from 621 GPs (47.8% response rate) indicated that: 75%ofrespondentswereawareoftheManual mostreceiveditfromtheRCPAinbookform useoftheManual(bythosewhowereawareofit)was86.6% 86%useditintheprevioussixmonthsandindicateditwasarelevant
resource themostimportantfactorsinfluencingusewasitsreadyaccessibility(51%)
andtheinformationwasrelevant(48%) thedirectimpactoftheManualwasverysmall(0.4%ofallpathologytests
influencedbytheManual),althoughitwasimportantforunusualorinfrequentlyorderedtests.
Feedback from 813 hospital doctors (9% response rate) indicated that: 61.5%(500)ofrespondentswereawareoftheManualpriortoreceivingthe
questionnaire awarenessbyinternyearincreasedfrom31%forthosewhowereinternsup
to1980,78%for1998(soonaftertheManualwasreleased)and52%in2001
67%ofthoseawareoftheManualindicatedtheyhadusedit theuseoftheManualwaslowestamongstinternrespondents(57.6%)and
highestamongstregistrars(68.9%)andresidents(68.3%) ofthosewhousedtheManual,32%didsointhepreviousthreetosix
months,23%withinthelastmonthand7%withinthelastweek theManualwasusedtodirectlyinform1.5%ofallpathologyrequests 86%indicateditdidnotchangethenumbersofpathologyrequests,butitdid
modifythetestprofileonabout50%ofoccasionswhereitwasconsulted theManualwasseenasanimportantreferenceresourceinthehospital
environmentduringtheformativeearlyworkingyearsinadoctor’scareer. Analysisoforderingpatternsviade-identifieddatafromtheHealth
InsuranceCommission(HIC)indicatedtherewerethreetestbundleswheretheManualprovidedspecificguidanceandallowedanalysis:
1. thyroidfunctiontest(TFT)2. ironstudiesversusserumferritin3. extractablenuclearantigenantibodies.
General conclusions were: doctorswhowereawareoftheManualaccepteditasanimportantreference
resourceandcontinuetouseit
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thelackofreprinting/distributionsince1997resultedinreducedawareness doctorssupportedthedevelopmentofanupdatedversion thetargetpopulationneedstobeperiodicallyremindedofitsexistence
throughappropriateeducationforums hospitaldoctorswouldbenefitbyhospitalsdevelopingalinktotheManual
ontheRCPAwebsiteviapathologyresultsreportingsystems futureManualsshouldbedistributedtonewmedicalgraduatesineachyear
ofcurrency.
Recommendations 1. ArevisedManualbedevelopedanddistributedtoGPsandnewmedical
graduates.2. FuturedevelopmentandreleaseoftheManual(orequivalentresource)
shouldincludeperiodic(atleastannual)distributiontograduating/new-graduatedoctorsandaremindersenttoallrelevantdoctorsaboutitsexistence.
3. SufficientcopiesofanyfutureManualshouldbeproducedtosatisfydemandbeyonditsinitialdistribution.
4. HospitalstobemadeawareoftheRCPAwebsiteversionoftheManualandencouragedtolinkittotheirpathologyreportingsystem.
5. AppropriateGPeducationandinitiativesshouldaccompanythedistributionoffutureversionsoftheManual.
6. ThefutureManual,orsimilarresources,shouldbedevelopedinvariousformatsincludingbook/hardcopyandelectronicformsandvariousstrategiesfordisseminations(includingassociatededucationalinitiatives)beadopted.
7. ConsiderlinkingthedevelopmentoffutureversionsoftheManualtoincorporatetheNationalAssociationofTestingAuthorities(NATA)requirementforlaboratoriestoproducesimilarresources.
8. ContinuetodevelopfutureversionsoftheManualinconjunctionwiththeRCPAandotherappropriateprofessionalcolleges.
9. Recommendationsforfutureprintedversionsincluded: colourcodekeyselectionssimilartotheMedicareBenefitsSchedule
(MBS)model includeanindex includehighlevelcostinformation includebasic‘operational’informationsuchastubecolours,collection
proceduresetc. includeguidelines/protocolsforpathologytestsforcommonconditions includesomeinformationaboutHIClimitationsoftests includespecificinformationontests,testfrequency,testbundlesand
acceptableabbreviationsfortests includeusefulsupplementarytestsandtestsnotindicatedbasedonthe
results identify‘normal’rangesandsensitivityindicatorsfortestresults includeturnaroundtimes considerationofproducingtheManualsincelaboratoriesproducesimilar
resourcesundertheNATArequirementforaccreditation.
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Key Project Learnings
Thesingledistributionin1997withoutfollow-upreducedawarenesslevelsamongstnewlygraduateddoctors.Only30%of2001internswereawareofandhadusedtheManual.
Manyhospitalsproducetheir‘own’versionoftheManualsettingoutorderingpracticesexpectedatthathospital.
ProvidingtheManualineitherhardcopyorelectronicformattoallmedicalstudentgraduatesensuresaccesstotheManual.
Theinitialcomponentofhospitalwork(internandfirstyearspostgraduation)providedthemostimportantknowledgeaboutpathologyorderingaslittlewasincorporatedintouniversityeducation.
Itmaybemorewidelyusedifprovidedtoeach‘ward’asopposedtoeachdoctor.
Follow on Initiatives and Projects
RCPAManualTransformationProjectonpage18.
Areas for Future Consideration
Deviseastrategyto‘remind’doctorsabouttheexistenceandusefulnessoftheManualatspecifiedtimeintervals.
Developguidelines/protocolsforpathologytestsforcommonconditions.
Revision of Manual of Use and Interpretation of Pathology Tests (2004)
Description ThisprojectupdatedthecontentoftheManualofUseandInterpretationofPathologyTests,andmadeitavailableviatheRoyalCollegeofPathologistsofAustralasia(RCPA)website(http://www.rcpamanual.edu.au/)inaformatfacilitatingsearching,downloadingandincorporationintoothersoftware.
Grant Recipient RCPA
Aim
toproviderecommendationsforfuturedirectionsincludingabusinessplanforfutureupdatinganddistributionoftheManualindependentofgovernmentfunding.
This aim was achieved by this project.
Findings
TheManualisquiteauniquepublicationbothwithinAustraliaandinternationally,andtheabsenceofcompetitorpublicationsoffersscopeforlimitedsaleswithinAustraliaandpotentiallyoverseas.
TheManualhasthepotentialtogenerateincomefromdistributioninseveralformats:
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o CDversiono printversiono labrequirementssubscription.
ThereissignificantdemandforprintandCDversionsoftheManualfromgeneralpractitioners(GPs),butsignificantresistancefromthemtopayingforit.
ThereappearstobeanawarenessamongstGPsthattheManualisbeingusedbytheCommonwealthasabehaviourchangeinterventiontochangepathologyordering,andintroducingstrongDigitalRightsManagement(DRM)provisionscreatesthepossibilityofanegativereactionfromGPgroups.
Recommendations 1. FutureversionsoftheManualcontinuetobedevelopedbytheRCPAin
conjunctionwithotherappropriateprofessionalcolleges.2. TheInternetandPDAversionsoftheManualcontinuetobeavailableatno
costandthroughunrestrictedaccessviatheInternetsite.3. Aregistrationprocessanddifferentiallicensingarrangementsbeundertaken
forthefollowingformatsoftheManual:o CDversion–non-commercialandcommercialonCDand
downloadableo printondemandhardcopyversiono subscriptionversion(CD,downloadandprint)o internationaldistributiono individuallaboratoryrequirementssubscription.
4. AduallicensingsystemshouldbeexaminedfortheManual.5. ThefollowingformsoflicensingbeimplementedfortheManual:
o non-commercialuseo singlepurchaseCDorhardcopybooko commercialuselicenceso subscriptionlicenceo internationallicensing.
Key Project Learning
TheManualitselfcontinuestoberecognisedasanimportantresourceforassistingpathologyorderingandinterpretation,andtobeusedbythemajorityofthosesurveyed.
Follow on Initiatives and Projects
RCPAManualTransformationProject(2010).
RCPA Manual Transformation Project (2010)
Description ThisprojectsoughttoupdateandtransformtheRoyalCollegeofPathologistsofAustralasia(RCPA)Manualtoreinforceitspositionasthepre-eminentsourceofpathologyinformationforhealthcarepractitioners,anddevelopaseriesof
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evidence-basedPathologyDecisionSupportTools(PDSTs)toguidereferringpractitionersinrequestingpathologytestsforthediagnosisandongoingmanagementandmonitoringoftheirpatients.
Grant Recipient RCPA
Aims and Objectives 1. toconveneaSteeringGrouptooverseetheupgradeoftheManualand
provideadvice,makedecisionsandcommentonanyamendmentstotheexistingManual
2. toreviseandupdatethecontentofthecurrentRCPAManual3. toupgradetheformattingoftheRCPAManualsoitiscomparabletoLab
TestsOnline(LTOAU),andalsotocreatealinkbetweenthetwowebsitessothetwoproductsareassociated
4. todevelopPDSTsanduploadthetoolsintotheRCPAManual.These aims and objectives were achieved by this project although a link to LTOAU could not be established due to the underlying technical format of the respective websites, as well as the way the content was set out. However, an external link to the LTOAU website was included on the RCPA Manual website.
Outcomes
Atthetimeofthereport,43PDSTswerecompletedandplacedontheRCPAManualwebsite.
TheManualhasbeenredevelopedtomakethewebsitemoreuser-friendly. TheRCPA’sinternalwebdeveloperwascontinuingtoattendtoongoing
maintenanceofthewebsite. Between22April2010and13December2010,38,470uniquevisitorshad
visitedtheRCPAManual67,756timesandviewed288,474pages.Italsoreceivedabout5,000uniquevisitors,8,500visitsand36,000pageviewsmonthly.
Finding
TheRCPAManualcontinuestobeusedbygeneralpractitioners(GPs)andotherreferringdoctorsthroughoutAustralia,andprovidesahandyreferencematerialformedicalstudents.
Recommendation 1. FutureworktotheManualwebsitemayinclude:
o developingaspecialversionforhandhelddevicessuchasaniPhoneorBlackberry
o promotingthewebsiteinternationallyo maintenanceo backupo regularcontentrevisionbasedonnewinformationo integrationwiththesoftwareusedbytheGPsandtheotherdoctors
(e.g.RoyalAustralianCollegeofGeneralPractitioners[RACGP]Primary Care Side Bar).
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Key Project Learning
ThefinalformattingbytheRCPA’sinternalwebdevelopertookconsiderabletimeduetotechnicalissuesbeforethePDSTsweretransferredontotheliveRCPAwebsite.
Areas for Future Consideration
Exploretheuseofonlinetoolsfortrainingandsupportofqualitypathology. ExplorehowtheRACGPandtheRCPAcanworktogethertointegrateand
enhancetheutilityofthePDSTstotheclinicalpracticeofrequesterssuchasanaccessiblelinktotheRCPAManualviaGP’sdesktops.
An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002)
Description Thisprojectsoughttoanalysechangesinpathologyorderingpatternsingeneralpracticebetween1998and2001andthepossiblecausalrelationshipsbetweenanyidentifiedchangesandotherfactorsbyundertakingananalysisoftheBetteringtheEvaluationandCareofHealth(BEACH)databetweenApril1998andMarch2001.
Grant Recipient UniversityofSydney
Aims and Objectives
toinvestigatechangesinpathologyorderingpatternsingeneralpracticebetweenApril1998-99andMarch2000-01,andthepossiblerelationshipsbetweenanyidentifiedchangesandotherfactors
Specifically: toinvestigatechangesinpathologyorderingpatternsoverthreeyears toinvestigatetheextenttowhichcharacteristicsofgeneralpractitioners
(GPs)havechangedoverthethreeyearsoftheprogram toinvestigatetherelationshipsbetween:
o changesinpathologyorderingandinGPcharacteristics(particularlyGPage)
o pathologyorderingandmorbidityundermanagemento pathologyorderingandlengthofconsultationo pathologyorderingandprescribingbehaviour,imagingordered,
therapeuticproceduresundertakenandclinicaltreatmentsprovided toinvestigatethefactorsthattogethersignificantlycontributetopathology
orderingbehaviour.These aims and objectives were achieved by this project.
Findings
TherehasbeenasignificantincreaseinpathologytestorderratesbyGPsbetween1998-99and2000-01.
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Therehasonlybeenasmallincreaseintheproportionofproblemsforwhichpathologyisordered,buttherehasbeenaverystrongmoveawayfromorderingasingletestperproblemtoorderingthreeormoretestsperepisode.
Themajorincreasewasforrequestsforchemicalpathology(+22.6%),withotherareasshowingsmallerincreases;Immunology(+20.1%),haematology(+13.5%),tissuepathology(+10.7%),microbiology(+5.5%),cytogenetics(+0.5%),infertility/pregnancytests(+1.5%).Therewasadecreaseinthenumberofsimplebasictests(-11%)andcytopathology(-1.2%).
Theoverallpathologyorderrateincreasedbyapproximately22%. Therewasaninverserelationshipbetweenpathologytestorderingand
pharmaceuticalprescribing,andapositiverelationshipbetweenpathologytestorderingandimagingtestorders,buttheirimpactonoverallratesofotherclinicalactivitieswasminimal.
Theincreasesarereflectedinpathologyorderedforallpurposes,particularlyfordiagnosticandpreventativecareandotherpathology,andtoalesserextentinmonitoringpathology.
Theprovenrelationshipbetweenconsultationlengthandpathologyorderingdidnothaveanyimpactonthechangesintotalpathologytestsorderedovertime.
WhileorderratesaresignificantlyrelatedtoGPcharacteristics,therehasbeennochangeinthecharacteristicsofGPssothisrelationshipcannotbethecauseofincreasedpathologytestorders.
Someoftheincreasecanbeexplainedbyincreasedmanagementratesofafewcommonconditions,however,themajorityofthemeasuredincreasecannotbeexplainedbyfactorsmeasuredinthisstudy.
ExternalinfluencessuchaschangesintheMedicareBenefitsSchedule(MBS),systemchangessuchasincreasedcomputerisation,andpossiblyincreasedfearoflitigationmustbeconsideredaspossibleinfluencesonpathologyorderratesofGPsovertheperiodofthisstudy.
Higherorderingrateswereassociatedwith:o largerpracticeso ruralandremotepracticeso higherproportionsofworking-ageadultpatients(aged15-64years)o highermanagementratesofproblemsassociatedwiththebloodand
blood-formingorgans,theendocrineandmetabolicsystems,thecirculatorysystem,pregnancyandfamilyplanningandurinogenitalproblems
o highratesofMedicareLevelC(long)consultations. Factorswhichmayhavebeeninfluentialinalteringthepatternsofordering
includechangestoguidelineswhichpromotemoreintensivemonitoringofpatients,amovetocomputerisedordering,medicalindemnityconcernsandincreasingemphasisonmanagingchronicdiseases.
Key Project Learnings
TheincreasesinthenumberandcostsofpathologytestsasrecordedbytheHealthInsuranceCommission(HIC)datadidnotnecessarilyreflectthetrueorderingpatternsofGPs.
Independentoftheeffectofvariablesassociatedwithhigherorderingrates,pathologyorderratesincreasedwithtime.
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AsignificantincreaseinpathologytestorderratesbyGPscouldnotbecompletelyexplainedbyfactorsmeasuredinthisstudy.
Follow on Initiatives and Projects
AsecondstageofthisprojectwasundertakenasEvidence-PracticeGapinGPPathologyTestOrdering:AComparisonofBEACHPathologyDataandRecommendedTesting(2009).
Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009)
Description ThisstudysoughttoidentifyGPpathologyorderingpatternsfromBettering the Evaluation And Care of Health (BEACH) Programdata2000-2007forhighcost,highuseandinappropriateitemstoenableanalysisofthepatternsagainstpublishedbest-practiceguidelines.Italsosoughttoexaminegeneralpractice(GP)pathologyorderingpatternsintheBEACHdataforproblemsmanagedingeneralpractice:
whichwereaNationalHealthPriorityArea ifpathologyorderingwascommoninthemanagementofthecondition ifthepathologyorderingbehaviourofGPshadchangedforthe
managementoftheproblembetween2000-2002and2006-2008(thedurationofthestudy).
Onthisbasis,Type2diabetes,hypertension,lipiddisorders,weakness/tiredness,‘healthchecks’andoverweight/obesitywereselectedforinvestigation.‘Healthchecks’problemsincludedcheck-upsrecordedbyGPsatencounterswithpatientsaged15yearsandover,andoverweight/obesityincludesproblemsmanagedthatwerelabelledbyaGPas‘obesity’or‘overweight’forpatientsaged18yearsandover.Allofthesixproblemsinvestigatedinthisstudyaccountedfor12.1%ofallproblemsmanagedin2000-08,andformorethanone-quarter(25.7%)ofthetotalpathologytests/batteriesrecordedbyGPs.
Grant Recipient UniversityofSydney
Aims and Objectives
toinvestigatetheextenttowhichGPs’pathology-orderingbehaviourforselectedproblemsalignswithrecommendationsmadeinnationalandinternationalguidelinesforthemanagementoftheseproblems(datausedwasfromaBEACHstudyovereightyearsfromApril2000tomarch2008)
toidentifywhetherchangeshaveoccurredinthepathologyorderedfortheselectedproblemsoverthelasteightyears,andwhetheranymeasuredchangereflectsachangetobe‘more’or‘less’inlinewithguidelinesrecommendations
toidentifytheextenttowhichmeasuredchangeshavebeentheresultofchangesin:
o themanagementrateoftheproblemand/or
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o thelikelihoodofpathologybeingorderedinthemanagementoftheproblemand/or
o explorethenumberofpathologytests/batteriesoftestsbeingordered.
These aims and objectives were achieved by this project.
Findings
Thepathologytestordersincreasedsignificantlyforallsixproblemsovertheperiodofthisstudy.Theseincreaseswereindependentofchangesinthemanagementrateoftheproblemandaccountedforabout31%ofthenationalincreaseinpathologytestsorderedforallproblemsfrom2000-2002and2006-2008.
IncreasesinthepathologyorderratesforType2diabetesandhypertensionwereduetoanincreaseinthelikelihoodofatleastonetestbeingordered,andanincreaseinthenumberoftestsorderedpertestedcontact.
Onlythelikelihoodoftestingincreasedforweakness/tirednessandoverweight/obesity.
Onlythenumberoftestsorderedpertestedcontactincreasedforlipiddisorders/healthchecks.
GPorderingbehaviouralignedwellwithguidelinerecommendationsforlipiddisorders(75.5%ofpathologytests/batteriessupported),weakness/tiredness(71.7%),Type2diabetes(72%)andhypertension(65%).Thelevelofsupportforlipiddisordersandhypertensionislikelytobeover-estimatedastestswereprimarilyrecommendedforinitialassessmentofnewlydiagnosedcaseswhereasthemajorityofpathologyorderedfortheseproblemswasforongoingmanagement.
Pathologytests/batteriesorderedbyGPsfor‘healthchecks’andoverweight/obesitydidnotalignwellwithrecommendedtesting.Only24.3%ofpathologytests/batteriesrecordedfor‘healthchecks’and50.9%foroverweight/obesitywererecommendedintheguidelines.
ThenumberoftestsorderedbyGPspertestedproblemincreasedovertheperiodofthisstudyandpotentiallyfurthercompoundedtheissueofdecipheringtruepositiveresults(realchange)fromfalsepositiveresults.Forexample,fullbloodcounts(FBCs)wereoneofthemostfrequentlyorderedtestsbutitwasonlyrecommendedinthemanagementofweakness/tirednessandintheinitialinvestigationofhypertension.Therefore,theresultssuggestGPsmayhavebeenopportunistically/routinely-orderingFBCswhenorderingbloodtests.
Theguidelinesreviewedweremorbidity-basedandcouldnotprovideguidancethatisapplicableforallpatients,especiallythosewithmultiplechronicconditions.
Recommendations 1. Providingguidanceonthevarianceofresultsinlongtermmonitoring
(coefficientofvariance)andlikelihoodofabnormaltestresultswhenmultipletestsareorderedmayimprovetheinterpretationandappropriateorderingofpathologytestsinprimarycare.
2. Thelimitationsofthisstudymeantthelevelofsupportcouldnotbedeterminedfor10-24%ofpathologytestsorderedforeachmorbidity.Either
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testswererecommendedforaspecificclinicalsituationthatcouldnotbeevaluatedwithBEACHdata,orGPsorderedbatteriesoftests(e.g.multibiochemicalanalysis)forwhichsupportcouldnotbedetermined.Furtherresearchisneededtodeterminewhethertheuseofthesetestsissupported.
3. Guidelinesandguidanceregardingpathologytestscouldbeimprovedby:o providingadequateadviceonthepathologytestsrequiredinthe
ongoingmanagementofeachcondition(e.g.recommendationsregardingmonitoringlongtermmedication)includingdetailonthefrequencyanddurationforwhichtestingisrequired
o providingadviceonthepretestprobabilityofdisease,particularlywhenrecommendinginvestigationofpossiblecausesofsecondarydisease
o informingGPsofthelikelihoodofintra-individualvariationwhenmonitoringlong-termconditions.Usingmedicalrecordsoftwaretoprovidegraphicalpresentationofresultsofrepeatedpathologytestswithmarkerstoindicatethecoefficientofvariationmaybeuseful
o educatingGPsonthelikelihoodoffalsepositiveswhenorderingmultiplepathologytests,particularlyinthecontextoflowpretestprobabilityofdisease
o standardisingterminologyusedtorefertopathologytestingtohelpGPslocateinformationregardingpathologytestingwithinguidelines.
4. TheclinicalindicationsfororderingFBCs,thyroidfunctiontests(TFTs),multibiochemicalanalysisandliverfunctiontests(LFTs)inthelong-termmonitoringofchronicconditionsneedsclarification.Furtherresearchorreviewofliteraturetodeterminethepretestprobabilityofunderlyingdiseasemaybeusefulindevelopingguidanceontheuseofthesetests.
5. EnsuringGPscanaccessresultsofpreviouslyorderedpathologytests(regardlessofwhoorderedthetest),andthatresultsareeasilyaccessiblewithintheelectronichealthrecordmaydecreasetherateofrepeatedpathologytesting.
6. ThelengthofguidelineswasperhapsthebiggestbarriertoGPsusingthem,particularlyasaquickreferencepointtolocateinformationaboutbestpracticeforpathologyordering,andwhentheyarenotapplicableintheclinicalcontextofmultiplemorbiditiesforonepatient.Therefore,developingotheravenuestoprovideguidancetoGPsaboutpathologyorderingmaybeusefulsuchasshortproblem-orientatedstatementsofrecommendedpathologytestsrelevanttothestageofmanagement(initialdiagnosisorlonger-termmanagement).
7. Adviceontestinginlong-termmanagementneedstoincludeinformationonexpectedintra-individualvariation(biologicalandanalytical),intervaltoretestanddurationforwhichmonitoringisneeded.Informationonthelikelihoodoffalsepositiveresultswhenorderingmultiplepathologytestsshouldalsobeprovided.
8. Wherethereisnoevidenceavailable,problem-basedconsensusstatementsshouldbedevelopedwithinvolvementofpracticingGPs.Thesenewguidancestatementscouldbeincorporatedintodecisionsupportsystemswithinelectronichealthrecords,linkedatthepointofthedecisiontoorderpathologytestsforthatproblemandatthepointofreceiptofresults.
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Key Project Learnings
LocatingrelevantAustralianguidelineswasnotastraightforwardprocess.Therewasnocentrallistingoftheavailableevidence-basedguidelines,andtheorganisationcreatingtheguideline/guidancedocumentvariesdependingonthemorbidity.TheNationalInstituteofClinicalStudies,whichispartoftheNationalHealthandMedicalResearchCouncil(NHMRC),wasdevelopinganationalclinicalpracticeguidelinesportalatthetimeofthereport.
GuidelinesareusuallynotdesignedforGPs.Theyareoftenverylongdocuments(often200+pageslong)anditisunrealistictoexpectGPstoreadlongdocumentsforallthemorbiditytypestheymanagement.
Informationregardingrecommendedpathologytestingwasoftendifficulttolocateinguidelinesastherewasoftennospecificsectionthataddressedinvestigationstobedone.Therewasalsomixedterminologyusedwithintheguidelinestorefertotestingsuchas‘diagnostictesting’,‘laboratoryinvestigations’,aswellasinthespecifictestnameorthediseasetobetestedfor.
Recommendationsregardingpathologytestinginthelong-termmanagementofconditionswereoftennotprovidedinguidelines.
ThevariationoftestresultswasoftennotdiscussedinguidelinesorothersourcesofGPguidance,withmostguidelinesprovidinga‘targetlevel’withoutprovidingfurtherdetail.
Follow on Initiatives and Projects
ThedevelopmentoftheNHMRCclinicalguidelinesaroundobesity.
Areas for Future Consideration
Requestereducationanddecisionsupportguidancestatements,especiallyfortheuseofFBC,TFTs,multibiochemicalanalysisandLFTsinmonitoringchronicdisease.
LiaisewithNHMRC/guidelinedevelopersregarding:o addingan‘investigations’sectioninguidelineso standardisingpathologyterminologyo includingpathologyrepresentationonguidelinedevelopment
workinggroups.
A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002)
Description Thisstudysoughttoexaminetheutilisationofpathologytestsingeneralpracticewheninvestigatingtiredness.Theclinicalrecordsselectedfortheprojectencompassedaseven-yeartimeframefrom1April1994to25April2001.Thesamplewasrandomlysortedand345patientswerevalidated.
Grant Recipient LuminisPtyLtd
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Aim
toexaminetheutilisationofpathologytestsintheinvestigationoftirednessingeneralpractice.
Objectives
todemonstratetheindicationsofpathologyintheinvestigationoftirednessingeneralpractice
toidentifyandfollowasampleofpatientswithtirednessandreviewthemanagementprocessesattheseencounters
toassesspatienthealthoutcomes todevelopandpilotcomputer-basedguidelinesforgeneralpractitioners
(GPs)investigatingtiredness.The aim and most objectives were achieved by this project. The final objective was partially met, with the study providing information that will enable progress to be made in the area of decision support.
Findings
SignificantlymorefemalesthanmalesvisittheGPwithtiredness. Olderpatients(>44years)comparedtoyoungerpatients(<44years)visit
theGPmorethanoncewithtiredness. Therewasameannumberof3.12testsrequestedperpatient. ThemostcommontestsorderedbyGPswere:
o fullbloodcountexamination(27%)o urea,electrolytesandcreatinine(18%)o thyroidfunctiontests(11.8%)o liverfunctiontest(10.8%)o testsfordiabetes(9.2%)o erythrocytesedimentationrate(8.7%).
Testslesscommonlyrequestedwere:o ironstudies(7%)o folatetests(3%).
Morefemales(56%)thanmales(46%)hadatleastonepathologytestordered,witholderpatientshavingsignificantlymorepathologytestsordered.
14%ofpathologytestswerereturnedabnormal,andonly3%ofthesepatientshadasignificantoutcomebasedonanabnormalpathologytestresult.
Patientswithahistoryofdepressionweresignificantlymorelikelytobetiredaftersixmonthscomparedtoapatientwithoutahistoryofdepression.
Asageincreases,thelikelihoodofhavingapathologytestincreases. Asthenumberofvisitsincreasesthentheprobabilityofhavingapathology
testsalsoincreases. Asageincreases,theprobabilityofhavinganabnormalpathologyresult
increases. As‘noproblem’changesto‘physical’thereisanincreasedchanceofan
abnormalresult,andchangesfromphysicaltopsychosocialalsoincreasesthechanceofanabnormalresult.
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Tirednesslastinggreaterthanfourtosixmonthsismorefrequentlyassociatedwithpsychologicalconditions.
Recommendations 1. Acompletebloodpicture,andpossiblefastingbloodsugarlevel,maybethe
appropriateandonlyinitialpathologyrequiredtoinvestigatetiredness.2. GPsshouldalwaysconductaclinicalreviewtodetermineifthereisevidence
ofdepressionorotherpsychologicalcondition,reviewthepatient’slifecircumstancestodecidewhetherstressesinwork,homeorrelationshipscouldbeafactor,andaphysicalexaminationtodetermineiflaboratorytestsarenecessary.
3. ApilotdecisionsupportstudyutilisingthefindingsofthisstudyhassignificantpotentialtomoveGPstomoreappropriatepathologyorderingandbetterpatientmanagement.
Key Project Learnings
Theevidenceforpathologytestsconfirmingadiagnosisrelatedtotirednessislimited.
Evidence-basedguidelinesforinvestigatingadultpatientswithfatigueoflessthansixmonthsdurationweredevelopedinOntario.
Areas for Future Consideration
DevelopaframeworkfordecisionsupportforGPsinvestigatingtirednessingeneralpracticebasedonelementsidentifiedinthestudy.
Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)
Description Thisprojectinvestigatedlaboratorymedicine(pathology)teachingpracticeandcurriculuminundergraduatetraininginstitutions(universitiesandteachinghospitals)acrossAustralia.
Grant Recipient HealthcareManagementAdvisors
Aims and Objectives
todeterminewhatiscurrentlybeingtaughtinregardtolaboratorymedicineinthemedicalcurriculum
toidentify:o ifcurriculacontentcomplieswithcurrentevidenceandbestpracticeo ifcurriculaaddressthepatternsand/orprevalenceofclinical
presentationsthatoccurwithinvariouspracticeenvironmentso what,whereandifapplicable,whygapsorinconsistenciesare
occurringinthecurrentteachingoflaboratorymedicineo anybarrierstotheeffectiveteachingoflaboratorymedicineo incidenceswherelaboratorymedicineteachingprogramsare
currentlyworkingwell toascertainwhoisteachinglaboratorymedicine
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toascertaintheoverseasexperienceinteachinglaboratorymedicinetomedicalstudents
toproviderecommendationstotheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)onwaystoimprovetheteachingoflaboratorymedicinetoenablemedicalstudentstodevelopbetterpathologyorderingandinterpretingskillstoassistinmanagingtheirpatients.
These aims and objectives were achieved by the project.
Findings
PathologyandlaboratorymedicineisintroducedinthefirstyearofprimarilyProblemBasedLearning(PBL)courses,andinthemiddleofmoretraditionallystructuredcourses.
Thenumberofcontacthoursforpathologyandlaboratorymedicineisestimatedatbetween250and300acrossallcurricula.
Ethicsandmedico-legalissuesareincorporatedintoallcurricula. Thevalueoforderingtestsforpopulationscreeningiscoveredinall
curricula. Thebasicknowledgeunderpinninglaboratorymedicineislargelytaught
throughlectures,tutorialsandpracticals. Theroleoflaboratorysessionsisdecliningacrossallmedicalschools. Allcurriculaprovideforstudentstogainexperienceintheuseofbasicpoint
ofcaretestsandcollectionofspecimensduringclinicalrotations. Computersareusedextensivelyinmedicalcurriculawithschoolsdeveloping
awiderangeofresourcestosupportstudentlearning. Thereisastrongemphasisondevelopingclinicalreasoninginthenew
curricula. Thefocusofteachinglaboratorymedicineisincreasinglyondisease
presentation. Therewerelimitedcaseswherethefinancialaspectsoftestingwere
considered. Arangeoftextswereused. Therewassomevariationintheinvolvementofpathologistsinteachingwith
anatomicalpathologiststhemostrepresentedinacademicdepartments. Cliniciansareextensivelyinvolvedinteachingstudentsintheirclinical
rotations. Anumberofissuesrelatedtobarriersandopportunitiesforimproved
teachingoflaboratorymedicinetoundergraduateswereidentified. Servicedemandsinpubliclaboratoriesandhospitalswerenotedasabarrier
togreaterpathologistinvolvementinteachingroles. Thereisadangerthatgoodhabitslearnedinundergraduateprogramscanbe
unlearnedshortlyaftergraduationasgraduatesundertaketrainingwithinclinicalteamsinpublichospitals.
IfcurrentteachingoflaboratorymedicineinAustraliaistoeffectivelypreparestudentstousepathologytestsappropriatelyintheirfuturepractice,theliteraturesuggeststhatteachingapproachesshould:
a. provideafirmgroundinginbasicbiomedicalsciencesandpathologyintheearlypartofthecurriculum
b. developanunderstandingofthelinkbetweenpathologyandclinicalpresentation
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c. facilitatethedevelopmentofsoundclinicalreasoningd. providestudentswithanunderstandingoftheapplicationof
pathologytestsasacomponentofteachingatthebeginningoftheirclinicaltraining.
Recommendations 1. Createafractional,temporarypositionineachmedicalschooltoprovide
supportandassistanceinvariousareas,andevaluatetheimpactofsuchpositionsafterabouttwoyears.
2. Commissionastudytoidentifyissuesorsituationsthatpresentdifficultiesforstudentsandrecentgraduatesinappropriatelyorderingandinterpretingpathologytestsandpresentthemtoaworkshop.
3. Commissionananalysisoflaboratorymedicineeducationinpostgraduateyearsoneandtwo.
4. Circulatethecorecurriculumdevelopedbytheheadsofacademicpathologydepartments,incollaborationwiththeRoyalCollegeofPathologistsofAustralasia(RCPA),tomedicalschoolsasaguideforfuturedevelopmentofcurricula.
5. DevelopaversionoftheManualofUseandInterpretationofPathologyTeststhatbecanstoredandaccessedonhandheldsystemssuchasPalm®,andanabridgedpocketversionofthisManualbedevelopedcoveringteststhatarelikelytobeusedonaregularbasis.
6. Providestudentswithmoreopportunitytovisitworkinglaboratoriestoimprovetheirunderstandingoftheprocessbywhichspecimensaremanagedandonhowreportsareprepared.
7. Specificallytargetedteachingfocusingonareaswhichundergraduatestudentsandrecentgraduatesfinddifficultwouldbebeneficial.
8. Supportclinicalteacherstomodelgoodpracticeintheuseandinterpretationofpathologyteststoimprovetestorderingandinterpretationpracticesamongstudents.
9. Expandtherangeofclinicalenvironmentsinwhichstudentsreceivetheireducation,trainingandexperiencetoenablethemtodevelopskillsappropriateformanagingthechronicandsubacuteconditionstheywillencounterintheirprofessionalpracticeinthecommunity.
Follow on Initiatives and Projects
ComputerAssistedPatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase1(iNvestigateProject)(2010) onpage 124.
Areas for Future Consideration
Focusonimprovingtheeducationofmedicalstudentsinundergraduatetraininginstitutions(universitiesandteachinghospitals)acrossAustraliainlaboratorymedicineaspertheaboverecommendations.
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Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003)
Description ThisprojectsoughttoundertakeananalysisofcurrentLaboratoryMedicine(Pathology)teachingpracticeinpre-vocationandgeneralpractitioner(GP)vocationaltraining.
Grant Recipient HealthcareManagementAdvisors
Aims and Objectives
toprovideacomprehensiveanalysisofhowlaboratorymedicineiscurrentlytaughtduringpre-vocationalandvocationalGPtraining
toidentifywheregapsexistinthecurrentteachingoflaboratorymedicineinpre-vocationalandvocationalGPtraining
toidentifyoptionsforteachinglaboratorymedicinemoreeffectivelyinpre-vocationalandvocationalGPtraining.
These aims and objectives were achieved by this project.
Findings Pre-vocational and Vocational GP Training Therelianceofclinicalteachinghasmeantpre-vocationalandvocational
trainingarecloselyrelatedtothepatternsandprevalenceofconditionswithinthepracticeenvironment.
Theoverallapproachtopre-vocationaltraininginAustraliaiscomparabletothatinotherEnglishspeakingcounties,withanemphasisonward-basedteaching.
ThecurriculumcontentforJuniorMedicalOfficers(JMOs)variesconsiderablywithinandacrossjurisdictions,asdoestheextenttowhichpathologytestorderingisincorporatedwithinthecurriculum.
Thecontentofteachingisdependentontheclinicalrotationandtheviewsandpracticesoftheconsultant,andoftheclinicalteammoregenerally.
Wherefinancialaccountabilitywastheresponsibilityofclinicalunits(atleasttosomeextent),theuseofpathologywasincorporatedintowardmeetingsandfeedbackprovidedtoJMOs.
Theprominenceofbedsideorward-basedteachinginthecurriculaforJMOscontributestoahighdegreeofvariationbetweenhospitalsites,andbetweenclinicalunitswithinasingleinstitution.Thisincreasestheimportanceofthepracticeofseniorclinicians.
Gaps in the Current Teaching of Laboratory Medicine Thereislimitedinvolvementofuniversitymedicalschoolsinvocational
trainingcomparedtootherEnglish-speakingcountries. Theuseandinterpretationofpathologytestshasalimitedfocuswithinthe
trainingprogramforGPregistrars. Therearedifferentprioritieswithgeneralpracticecomparedtoteaching
hospitalpractice.
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Theinvolvementofpathologistsinclinicalteachingandreviewofcasesislimited,partlyduetothelimitednumbersofpathologistsandthedemandsplacedonmodernlaboratories.Therewasalsominimalglobalguidancebypathologistsregardingoveralldiagnostictestingstrategies.
MostattentionisfocusedontestsJMOsdidnotorderratherthanonthetestsordered.ThereportedlackofconsensusamongseniorclinicianswasidentifiedbyJMOsasafactorthatlimitedtheirabilitytogainanunderstandingofappropriatepractice.
AJMOisunlikelytoquestionorchallengethepracticeofaseniorcolleagueintheexistingcultureinthemedicalprofessionwhichischaracterisedbyautonomy,competitivenessandhierarchy.Forexample,JMOsorderteststhatparticularconsultantsalwaysrequesttoavoidtheriskofembarrassmentduringwardrounds.Thereisalsoexaminationandfeedbackregardingwhatwas‘not’ordered,sooverorderingispracticedtoavoidembarrassment.
JMOshavelimitedaccesstoorexperienceinalaboratory,butthereisvariationacrosssiteswithgreateraccesstobothpathologistsandthelaboratoryinruralsites.
Barriers to improving how JMOs learn about the ordering and interpretation of pathology tests include:
thelackofincentivesforlaboratoriestoreduceordering thelackofconsensusamongstconsultants medicolegalconcerns makingpathologyteachingrelevantandinteresting thebalancebetweenstaffspecialistsandvisitingmedicalofficers increasingsub-specialisation theviewofthelaboratoryasa“blackbox” changedworkinghoursforJMOshavereducedtherangeofcasesthey
seeandtheextenttowhichtheyareinvolved theshortageofpathologists.
Options For Teaching Laboratory Medicine Interventionswhichtargetonlyonefactorcontributingtotestorderingare
likelytohavealimitedimpact.ThelinkagebetweeneducationofJMOs,feedbacktoconsultantstaffandbuildingconsensusaroundanacceptedevidencebaseappearstopresentacomprehensiveapproachtochangingpractice.
Akeyconsiderationonthevalidationofknowledgewithinthemedicalprofessionrelatestothelocationofthesourcewithinaprofessionalhierarchy.
Personalpreferencesandknowledge,theenvironmentinwhichpracticeoccursandthefeedbackprovidedwithinthatenvironmentaffectstheapproachtakentoorderingtestsbyindividualmedicalofficers.
Giventherelianceonclinicalteaching,bothprevocationalandvocationaltrainingarecloselyrelatedtothepatternsandprevalenceofconditionswithinthepracticeenvironment.
Wherehospitalshaveintroducedprotocolsfortheutilisationofhighcosttests,JMOsindicatedtheywereusefulininformingthemofappropriate
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practice,anddiminishingtheriskoffindingthemselvestakingapositionthatmaybeinconflictwiththeirconsultant.
Internsandresidentsidentifiedregistrarsasamajorsourceofinformationguidanceandteaching.
General Findings Thereisahighlevelofcontactmaintained(usuallybytelephone)with
pathologistsinrelationtotestsorderedandtheirinterpretation. Registrarstypicallyorderconsiderablylesstestswhentheymovefrom
hospital-basedpracticetocommunity-basedgeneralpractice. Patientexpectationscaninfluencethedecisiontoorderpathologytests. Therearelimitedincentivestodevelopmoreeffectiveapproachestotheuse
ofpathologyassavingsweredivertedtootherareasofthehospitaloperation.Initiativestoreducevolumeoftestsorcostsshouldfocusonawholesystemapproachratherthanonaspecificunitorsectorofahospital.
Barriers to change include: patientexpectations concernregardingpossiblelitigation environmentinwhichprevocationaltrainingoccurs potentialconflictofinterestforpathologistsemployedintheprivatesector perceptionofgovernmentsourceinformationandmaterial lackofdirectcosts.
Recommendations 1. TheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)should
considerallocatingresourcestosupporttheexpansionoftheRationalInvestigationOrdering(RIO)collaborative.
2. DoHAshouldconveneaworkinggroupwithrepresentativesoftheStatesandTerritoriestogainsupportforarequirementthatacomponentofsavingsresultingfromtheRIOcollaborativebeallocatedtosupportincreasedinvolvementofpathologistsinthetrainingofJMOs.
3. AcriterionforthesupportofindividualproposalstotheRIOcollaborativeincludeaprojectcomponenttoemphasisethevalueandimportanceofclinicalassessmentincludinghistorytakingandphysicalexamination.
4. FundingshouldbeallocatedtosupporttheRoyalCollegeofPathologistsofAustralasia(RCPA)todevelopaManualforUseandInterpretationofPathologyTestsasamoduleofcurrentGPpracticemanagementsystems.
5. AworkinggroupinvolvingDiagnosticsandTechnologyBranch,RoyalAustralianCollegeofGeneralPractitioners(RACGP)andtheRCPAshouldbeestablishedtodevelopapublicityprogramraisingawarenessthatorderingpathologytestsisnotanindicatorofthequalityofmedicalcarebeingprovided.
6. TheCommonwealthshouldsupporttheRACGPandRCPAtoprepareapathologyauditpackageforGPs.
7. TheCommonwealth,inseekingtosupportthebroaderimplementationoftheRIOprogram,negotiateswithStateandTerritoryHealthAuthoritiesforallocationofaspecificproportionofsavingsgeneratedtoprovidetimeforpathologiststobelocatedonwardsinmajorteachinghospitalsinalljurisdictions.
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8. ComprehensiveapproachestoprovideopportunitiestoenhancethelearningachievedbyJMOsshouldbedevelopedby:
o improvingtheknowledgebaseofJMOsthroughtargetededucationo providingdetailedauditandfeedbackregardingtestordering
practiceso developingconsensusregardingtheappropriateapplicationof
pathology.9. OpportunitiesforimprovinghowJMOslearnabouttheorderingand
interpretationofpathologytestsinclude:o theestablishmentofprotocolsreflectingconsensusregarding
appropriatetestorderingo theimplementationoftheRIOprogrammoregenerallyo thefocusonhighvolume,lowcosttestso theapplicationofsavingsgeneratedthroughpathologyo theincreasedroleofpathologistsonthewardso includingGPandcommunityrotationsinJMOtrainingo utilisingcomputertechnologytoreduceduplicationandinappropriate
orderingo increasingtheemphasisongoodclinicalhistorytaking.
10. OpportunitiesforimprovingtraininglearningandpracticerelatedtopathologytestorderingandinterpretationforGPsundergoingvocationalinclude:
o afocusonprevocationaltrainingo inclusionoftheManualforUseandInterpretationofPathologyTests
onsoftwaresuchasMedicalDirectoro establishmentofanindependentadvisoryserviceo educationofpatientstomodifyexpectationso developmentofanationalmodulerelatedtopathologytestingo developmentofasupportedContinuingProfessionalDevelopment
(CPD)auditpackageforGPso focusoncommunicationskillso inputbypathologiststokeepthemup-to-date.
Follow on Initiatives and Projects
BenefitsandRisksofPathologyTesting(Current) onpage159.
Areas for Future Consideration
Instigateglobalguidancebypathologistsregardingoveralldiagnostictestingstrategies,especiallyforJMOs,intheformofclinicalpathwaysand/orviaaconsensualapproachwithinclinicalteamsorunits.
InvestigatetheviabilityofplacingpathologistsinhospitalwardstomentorJMOs.
Investigatetheviabilityofprovidingdetailedauditandfeedbackregardingtestorderingpractices.
ImprovetheknowledgebaseofJMOsthroughtargetededucation.
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A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003)
Description Thisreportfocusedoninappropriatepathologytestinginhealthcareandhowbesttofacilitateevidence-basedbestpracticeinthefaceofrapidlyexpandingknowledge,risingconsumerexpectationsandgovernmentconcernsaboutunsustainableincreasesinhealthcosts.
Grant Recipient TherapeuticGuidelinesLtd
Aim
torecommendamechanismforthedevelopment,implementationandevaluationofevidence-based,bestpracticeclinicalguidelinestofacilitatequalityuseofpathology.
This aim was achieved by this project.
Findings
Theliteraturereviewrevealedthatguidelinesaloneareusuallyunsuccessfulinimplementingpracticechange.
Amechanismisrequiredtocoordinateandlinkpathologyguidelinesdevelopment,softwarevendorsandeducationalserviceproviders.
Cliniciansandconsumerswantintegratedandconsistentknowledgeresources(pathologyand/orradiologicalexaminations,therapeuticand/orpreventativemanagementandpatienteducation),notanumberofoverlappingandinconsistentresourcesindifferentformatslackingacommonclinicalproblemindex.
Coreclinicalguidelinesresourcesshouldbe:o accessiblefromthehealthworker’selectronicdesktop(general
practice[GP]andhospitalpractice)o enteredthroughacommonclinicalproblem(includingcommon
synonyms)o displayedinasimilarformato ideallyhaveatwotofivesecondresponsetimeo belinkedtorelatedresourceso ultimatelybecapableofassistingrecommendedactions.
Variouslevelsofcomputeriseddecisionsupportarepossible. Consumerswantbettercommunicationwiththeirhealthprovidersabout
diagnostictests,andmanywouldappreciatetheopportunitytoaccessconsumerfriendlyinformationabouttestsrecommended,includingtheirlimitationsandimplicationsoflikelyresults.
Therearevariedviewsaboutthecontentandformatofbestpracticeclinicalguidelinesfortheorderingofpathologytests.
ItisdifficultforGPstodistilevidence-based,bestpracticerecommendationsfromtheincreasingvolumesofscientificliterature.
Animportantconsiderationisthelimitedresearchbasewhenitcomestotheappropriateuseofpathologyandbestpractice.
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AnumberofstudiesreportedareductioninpathologytestingratesafterguidelineswereintroducedintoAustralianhospitals.
Recommendations 1. Developamechanismforthedevelopmentofpathologyguidelines.2. Developanappropriateformatfortheguidelines.3. Disseminateandimplementtheguidelines.4. Incorporatetheguidelinesintocomputerdecisionsupportsystems.5. Assesspractitioneracceptanceoftheguidelines.6. Assesstheeffectivenessofguidelinesininfluencingpatientoutcomes.7. Developrelatedpatienteducationalmaterial.Principles guiding this report’s recommendations were: Themechanismshouldensurethatpathologyguidelinesareproduced
accordingtobest-practiceprinciples. Themechanismshouldbringtogetherkeyinformationproviderswho
currentlyproviderecommendationsconcerningpathologytestsinordertofacilitateconsistencyofrecommendationsandavoidunnecessaryduplicationofeffort.
Themechanismsshouldfacilitate(overalongertime-frame)theintegrationofelectronicpathologyguidelinesintomorecomprehensive,machinereadable,electronicinformationresourcestoenablecomputerisedpoint-of-caredecisionsupportandpracticeevaluation.Thiswillrequirebringingtogetherpathologyandotherprofessionalstoachievethis.
Themechanismneedstoaugmentprintandelectronicpathologyguidelineswithholistic,multi-dimensionaleducationprogramstoachievechange.
Areas for Future Consideration
Developevidence-based,bestpracticeguidelinesfortheappropriateuseofpathologyforGPs.
Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004)
Description Thisprojectsoughttodemonstrateproof-of-conceptforanationalprogramformoreinformeduseoftheProstateSpecificAntigen(PSA)testbyAustralianpractitioners,andtofurtherinvestigatetheusefulnessofacademicdetailing(AD)forsupportofbetteroutcomesfromtheuseofdiagnostictechnologies.ThiswasanextensionofworkontheCommonwealthofAustralia’sproof-of-conceptprojectforanationalprogramformoreinformeduseofthePSAtestbyAustralianGeneralPractitioners(GPs):1February2001to31August2003.ItalsoincorporatedinformationfromthestudyoncolorectalcancerandHelicobacter pylori (H. Pylori)visitingprogrammes.
Grant Recipient DrugandTherapeuticsInformationService(DATIS)
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Aims and Objectives
todemonstrateproof-of-conceptforanationalprogramformoreinformeduseofthePSAtestbyAustralianpractitioners
tofurtherinvestigateusefulnessofacademicdetailingforsupportofbetteroutcomesfromtheuseofdiagnostictechnologies.
These aims and objectives were achieved by this project.
Findings PSA Screening Approximately50%ofGPs(n=162)surveyedinMelbourneadheredtothe
currentAustralianguidelineswithrespecttoPSAscreening. ManyGPsdidnotsupporttheideaofPSAscreeningforavarietyofreasons
althoughtheyviewearlyknowledgeofprostatecancerasbeneficial,regardlessofwhattheguidelinesorevidencepropose.
ManyGPsarestilllikelytobeinfluencedbytheirownanecdotalexperience. ManyGPsareconfusedregardingthecontroversyandpotentialrisksand
benefitsofPSAscreening,andtherewasuncertaintyabout‘whichwaytogo’whenfacedwithapatientrequestforPSAscreening.
OnlyaverysmallnumberofGPswereinterestedinalternativePSAmeasurements(e.g.freetototalPSA,PSAvelocity),orintheconceptsofsensitivity,specificityandpositivepredictivevalue(PPV).
Medico-legalissuesareamajorinfluenceonGPsfulfillingpatientrequestsforPSAscreening.Thepotentiallong-terminfluenceofthisisthestandardofcareofferedbyGPsmayultimatelybedeterminedbyfearofmedico-legalrepercussionsratherthanbeingbasedonbestpractice.
GPswithyoungerpatientstendedtoorderfewerPSAtests,whileGPswitholderpatientstendedtoordermore.
ManyGPssupportedshareddecision-makingandrecognisedtheimportanceofhelpingpatientsunderstandthebenefitsandrisksofPSAscreening.
ManyGPsfoundwrittenmaterialadvantageousinassistingwithshareddecisionmaking,whiletheelectronicdeliverymodeofinformationwasnotanimportantissue.
AhighproportionofGPscommentedfavourablyontheMr.PHIPmaterials. ManyGPswantedtoretainthevisualdetailingcardsfromtheprostate
cancertopic. ManyGPsaffirmedthatinthecurrentmedico-legalclimateregardingPSA
testingitwasmoreimportantthanevertobeawareoftheevidenceandtoremain‘balancedandsensible’aboutthescreeningissue.
IttookthreeorfourvisitsbyDATIStochangeGPbehaviourorattitudetoPSAscreening(recordedduringcolorectalcancerscreeningvisits).
Colorectal Cancer Screening TherewasmixedusedofcolorectalscreeningamongstGPs. Therewasincreasedinterestincolorectalscreening,especiallythefaecal
occultbloodtest(FOBT)aftertheDATISvisits. Thereweremixedconcernsaboutthedifferentscreeningmethodsinterms
ofpatientexperienceandbarrierstousingtheme.g.dietrestrictions,handlingstools.
AsmallproportionofGPsaskedtokeeptheDATISdetailingaids.
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TherewasmixedresponsestotheMrPHIPmaterials.H. Pylori TherewasinterestamongstGPsaboutH. pyloriandclinicalmanagement
strategies. Gastro-oesophagealrefluxdisease(GORD),non-ulcerdyspepsia(NUD)and
non-steroidalanti-inflammatorydrugs(NSAIDS)wereissuesrelatedtoH. pylorithatGPswereuncertainabout.
ManyGPsusedprotonpumpinhibitors(PPIs)asaninitialstrategyforuninvestigatednon-GORDdyspepsia.
Themostestablishedandfrequentlyusednon-invasiveH. pyloritestwastheureabreathtest(UBT).
Therewasmixedreactionstothe“test&treat”or“search&treat”strategiesforlong-termPPIusers.
MayGPsagreedthatPPIswereoverusedandshort-termusecanleadtolong-termuse.
ManyGPsviewedserologyfavourablyonthesecondDATISvisit.Overall(OnlythefindingsrelevanttopathologyhavebeenincludedasopposedtofindingsspecificallyrelatedtotheDATISservice.) TheDATISacademicdetailingprogramonthetopicsofpathologytestsin
prostatecancer,colorectalcancer,type2diabetes(notincludedinthisreport)andH. PyloriinfectionhasahighacceptabilityamongstGPindifferentAustralianStatesandwaseffectiveinimprovingGP’sknowledgeandself-reportedpractice.
ParticipatingGPshighlyvaluedtheDATISeducationalvisitsandmaterials.AcommonthreadinfeedbackfromGPswastheyvaluedtheinformationprovidedintermsofitsimpartiality,clinicalrelevance,practicality,thoroughresearchandmethodofpresentation.
Recommendations 1. AnationalstrategyforachievingmoreinformedchoicesbetweenGPsand
theirpatientswithrespecttoprostatecancerissuesisurgentlyneededincontemporaryAustralia.
2. DATISservice-oriented-ADisamethodologysuitabletobeusedasafoundationwithinaneedednationalstrategy.Ithasbeenshowntobeeffectiveinthe1998-99studyrelativetocheaperapproacheswhichwerefoundtobeineffective.
3. AnumberofuncertaintiesaboutDATISservice-oriented-ADinthiscontextneedtobeexaminedbeforeexperimentallyderivedevidenceabouttheeffectivenessofDATISmethodscouldreasonablybetranslatedintopublichealthpolicyaction.
Key Project Learnings
Medico-legalaspectsofPSAscreeningwereamajorissueforthemajorityofGPsvisited,andperhapsthegreatestsinglemotivatorastowhyGPsfulfillpatientrequestsforthePSAtest.
ManyGPsfeelvulnerableandunconfidentwhendealingwiththeissuesandcontroversysurroundprostatecancerscreening.
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Follow on Initiatives and Projects
CommonwealthinvestmentinNationalPrescribingService(NPS)academicdetailingstrategiesfordiagnosticservices.
Common Sense Pathology (2006)
Description CommonSensePathology(CSP)wasapublicationseriesproducedprimarilytoassistGPsindeterminingappropriatepathologytests.Itranforsixeditions,comprisedaseparatelyboundeight-pageA4supplementwithgraphicartworkand/orphotosappropriatetothetopicandwasincludedintheAustralian Doctormagazine.AlleditionswerepostedontheRoyalCollegeofPathologistsofAustralasia(RCPA)website(http://www.rcpa.edu.au)withinonemonthofpublication.
Grant Recipient RCPA
Aim
toimproverationalandcost-effectiveutilisationofpathologytests.It is not clear if this aim was achieved although general practitioners (GPs), other doctors and medical students indicated the CSP articles were a valuable source of information.
Outcomes [alt=“ThefollowingtableliststheeditionoftheAustralian Doctormagazine,againsttheCSParticleandtheauthor/s”]
EDITION ARTICLE AUTHOR/S 7April2006 Malabsorption DrDannyStielandDrPaulO’Farrell2June2006 ViralHepatitis ProfYvonneCossart7July2006 MicroUrine ProfSydBellandDrAlexOuthred4August2006 Genital
InfectionDrAndrewDaleyandDrSuzanneGarland
1September2006 Lipids DrDavidSullivanandDrDavidTognarini3November2006 IronStudies DrAlanRMcNeilandEmeritusProfJackMetz
CSParticlesontheRCPAwebsitereceived340‘hits’bytheendofDecember
2006. TheRCPAcoveredallitsadministrativecosts,andtheauthorsoftheCSP
articleswerenotpaid,andnorwastheCSPEditor,astheseroleswerehonorary.
Findings
AnAustralian DoctorgeneralreadersurveyfoundthatCSPwasavaluablesourceofinformationforGPs.
Pathologistswerekeentocontributetothepublicationasauthorsastheyconsideredittobeaneffectivecommunicationtool,werehelpingGPsandinvolvingtheminthepathologyprocess.
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CSPhelpspreventunnecessarytestingresultingincostsavingsandavoidanceofinvasiveteststhatarenotwarranted.
CSPpromotesgoodpatientcareandcosteffectivepatientmanagementbyhelpingtopreventpotentialmisdiagnosesthatmayoccurbyomittingimportanttests.
CSPsavescostsofhealthcareasmanagementcanbeinstigatedatanearlierstageofdisease.
Recommendation 1. DrMatthewMeerkin,RCPACSPEditor,suggestedthatacompilationofthe
last24issueswouldbeausefuladditiontothelibraryofGPs,pathologistsandmedicalstudents.
Key Project Learnings
Asthepathologistswritingthearticlesdonatedtheirtime,theissueoftimelineswasmanagedby:
o securinganauthor’sagreementtowritethearticleswellinadvancewhereverpossible
o providingregularremindersfordeadlineso shorteningdeadlinesfordeliveryofarticlestotheRCPAtoallowfor
unforeseendelays. Toensurethetonewasappropriatefortheintendedaudience:
o authorswereaskedintheirletterofinvitationtowriteatalevelwhichwilleducateGPswithexplanatoryguidelinesprovided
o theRCPACSPEditorsometimesrequestedsendingthearticletoaGPwithaninterestinthespecifictopicbeforepublicationtotestitseffectiveness.
Difficultieswithearlyarticlesexceedingthewordlimitimposedbythepublisherdidnotrecur,andtheselimitswereclearlydefinedincorrespondencetoprospectiveauthors.Timewasalsobuiltintodeadlinestoenablearticlesthatweretoolongtoberevised.
Follow on Initiatives and Projects CommonSensePathologyPublicationSeries(2011).
Common Sense Pathology Publication Series (2011)
Description TheCommonSensePathology(CSP)publicationseriesforgeneralpractitioners(GPs)highlightsareasthataretopicalorproblematicindiagnosisormanagement.ThetopicsarechosenafterconsiderationoffeedbackfromAustralian Doctormagazineresearchabouttopicsofinterest,aswellasviafeedbackfrompathologistsaboutareasoftheirpathologyspecialtythatappeartobeconfusing,controversialorfrequentlymisunderstoodbyGPs.CSPwasdeliveredwithAustralian Doctormagazineto21,000recipients(whichessentiallyencompassedeverypracticingGPinAustralia).All2010/11editionswerepostedontheRoyalCollegeofPathologistsofAustralasia(RCPA)website(http://www.rcpa.edu.au/)withinonemonthofpublication.Issuesdatingback
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to2002werealsoavailableontheAustralian Doctorwebsite(http://www.australiandoctor.com.au/).
Grant Recipient RCPA
Aims and Objectives
toproduceaseriesofarticlesonareasthataretopicalorknowntobeproblematicwhenitcomestodiagnosisandmanagementbyGPs
toprovidepractical,relevantinformationaboutappropriatepathologyorderingforGPs.
Theseaimsandobjectiveswereachievedbythisproject.
Outcomes [alt=“ThefollowingtableliststheeditionoftheAustralian Doctormagazine,againsttheCSParticleandtheauthor/s”]NUMBER EDITION ARTICLE AUTHOR/S
1 29October2010 TiredAlltheTime DrSteveFlecknoe-Brown2 18February2011 GeneticInvestigationof
ChildrenDrSuiYu&DrNicolaPoplawski
3 1April2011 VitaminD DrMargaretJanu4 3June2011 CoeliacDisease DrDavidGillis
Findings
Australian Doctors’ownresearchhasshownthatclinicalinformationisthemostpopularareaofthepublicationwithresearchsuggestingover85%ofallGPsarereadingsectionsentirelyfocusedonclinicaltopics.
ReedPublishingadvisedtheybelieveCSPservedasausefuladjuncttothepromotionofappropriateordering,interpretationandfollow-upofpathologytestingbyAustralianGPs.
Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009)
Description Thisprojectsoughttoidentify,designandpilottheuseofsynopticformsandreportingprotocolsforcolorectalcancer.
Grant Recipient UniversityofNewSouthWales
Aims and Objectives
toidentify,designandpilottheuseofsynopticformsandtheimplementationofprotocolsthatwillreducereportvariabilityandpromoteconsistencyandreliabilityofpathologyreportingincolorectalcancer
theIPREPteamwillconsultwithpathologists,surgeonsandoncologiststopromotecommunication,collaborationanddisseminationofknowledgeregardingbestpracticeguidelinesandevidence-basedreporting.
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These aims and objectives were achieved by this project.
Outcomes
Thesynopticsurgicalrequestformandsynopticsurgicalrequestreportweredesignedforthereportingofcolorectalcancercasesalongwithasetofaccompanyingguidelines.
ThesedocumentsweredistributedintheircurrentformtoallindividualpathologistsandpathologylaboratorieswhichservicedtheSouthEasternandIllawarraAreaHealthService(SEIAHS).Theyweredistributedviaface-to-facemeetingswithacontactpathologistineachlaboratory.
AdditionalelectroniccopiesofthedocumentswerecirculatedviaemailandcouldbedownloadedfromtheColorectalCancerResearchConsortium(CCRC)website.
Thedocumentswerealsodistributedtooncologistsandsurgeonsthroughattendanceatmultidisciplinaryteammeetingsateachhospital.
AreviewofpathologyreportsfromeachpathologylaboratorywithintheSEIAHSwasconductedatthreedifferenttimepointstovalidatethepracticaluseofthesynopticdocumentsandguidelines.
Nationalconsensusandexpertopinionwastobesoughtforthecolorectalsynopticreportsandguidelines.
Colorectalworkingpartymeetingswereconductedon:o 24October2008inaface-to-faceforumo 18December2008viateleconferenceo 12February2009viateleconference.
Thisworkingpartyincludedmedicalspecialistsfromthefieldsofpathology,surgeryandoncology,aswellastheprojectmanagersoftheIPREPandCancerInstituteNSW(CINSW)StructuredPathologyReportingStandardsforCancer(2009) project.
TheIPREPprojectmanagerattendedbi-monthlyworkingpartymeetingswiththeCINSWprojectmanagerandrepresentativesfromtheRoyalCollegeofPathologistsofAustralasia(RCPA)andCancerAustraliatofinalisetheguidelinesforratificationfrombothofthesebodies,andforsubmissionoftheguidelinesforapprovalfromtheNationalE-HealthTransitionAuthority(NeHTA).
Follow on Initiatives and Projects
StructuredPathologyReportingStandardsforCancer(2009).
Structured Pathology Reporting Standards for Cancer (2009)
Description Thisprojectsoughttoleadthedevelopmentofanagreedmethodandstructurefordeveloping,disseminatingandmaintainingguidelinesforstructuredpathologyreportingofcancer.
Grant Recipient CancerInstituteNSW
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Aim
toleadthedevelopmentofanagreedmethodandstructurefordeveloping,disseminatingandmaintainingguidelinesforstructuredpathologyreportingofcancer.
This aim was achieved by this project.
Outcomes
Thesixprotocolsdevelopedwere:melanoma,prostate(radicalprostatectomy),lung,colorectalandlymphomabasedontheFrameworkdocuments.TheNationalBreastandOvarianConsortium(NBOCC)agreedtoreformattheirguidelinestothedevelopedframework.
WorkwasalsoinprogresstodevelopHealthLevelSeven(HL7)messagingstandardsandarchetypesinconjunctionwiththeNationalE-HealthTransitionAuthority(NEHTA)
Key Project Learnings
AkeypartofthisprojectwasdevelopingtheFrameworkforDevelopingProtocolswhichwasthenusedtodevelopsixcancerspecificprotocols.
FeedbackfrompublicconsultationonfiveofthesixprotocolshighlightedanumberofpointsonthegeneralstructureandapproachoftheprotocolswhichenabledtheFrameworkcommitteetorevisethedocuments.Thiswillassistdevelopersoffutureprotocols.
Follow on Initiatives and Projects
PromotingandExpandingStructuredPathologyReportingofCancer(Stage2)(Current).
Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current)
Description Thisprojectisseekingtopromoteandexpandtheuseofstructuredreportingofcancer.Thefinalreportisdueon16June2012.
Grant Recipient RoyalCollegeofPathologistsofAustralasia(RCPA)
Aims and Objectives
toundertakeanationalprogramofeducationonthepreviouslydevelopedcancerprotocols(breast,melanoma,lung,lymphoma,colorectalandprostate)
todevelopfurtherprotocolsinconjunctionwithinternationalbodies toundertakealiteraturereviewofpathologycancerreportstoprovide
informationonbestpracticereportingformatsthatenhancetheirunderstandingandreadabilitywiththeaimofcontributingtoimprovedpatientcareandsafety
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tosharethefindingsoftheliteraturereviewtoprovideadviceandfeedbackandparticipateasamemberoftheCollaborativeManagementGroupandasapartnerwiththeUniversityofMelbourneandDianellaCommunityHealthontheprojectEffectiveCommunicationofPathologyResultsinRequestingPractitionersandConsumers(Current)onpage 133
toworkcollaborativelywithProfessorJonPatrickattheUniversityofSydneytodevelopamodeltoautomaticallyreviewprotocolcontentanddevelopabaselineforthestructuredreportingofcolorectalcancer.
This project is current and the aims and objectives are in the process of being achieved.
Outcomes Theproject’saimsandobjectivesarebeingachievedinthefollowingstages: Establishgovernancefortheproject. Establishongoingmaintenanceandupdateprotocolsincludingpublication
andmediarelease. Developadditionalprotocolsandaformatforreportingstructured
information.Inaddition,workwithotherorganisationstoenabletheuseoftheprotocols.
Developadditionalprotocolsavailableforothercommoncancersincollaborationwithinternationalorganisations.
Reportonupdatingandpublicationofprotocolsandcommencealiteraturereviewofpathologycancerreports.
AuditofcolorectalstructuredreportinginassociationwiththeClinical Language Processor Engineproject.
CompletionoftheprojectandprovisionofaFinalReport.
Areas for Future Consideration
Possibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.
Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009)
Description Thisprojectsoughttodevelopspecificlaboratoryguidelinesandrecommendedprocedures(theGuidelines)toensurebestpracticeindealingwithsuspectedcasesofBloodBorneVirus(BBV)transmissioninhealthcaresettingsandthusreducethelikelihoodandimpactofBBVtransmission.
Grant Recipient SouthEasternAreaLaboratoryServices(SEALS)
Aims and Objectives
todevelopspecificlaboratoryguidelinesandrecommendedprocedurestoensurebestpracticeindealingwithsuspectedcasesofBBVtransmission
tocreateanAustralia-wideforumfordiscussionoftheguidelines
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toidentifyfacilitiesineachStateformolecularepidemiologyinvestigationstudies
toadvisepublichealthprofessionals,pathologists(includingtheRoyalCollegeofPathologistsofAustralasia[RCPA])andpolicymakersonthebest-practiceevidence-basedlaboratoryproceduresindealingwiththesecases
tointerfacewithhealthcareworkersandthecommunityatlargeonbasicinformationonBBVtransmissionviaconsultation,websiteandcollaboration.
These aims and objectives appear to have been achieved. The report states some were still in progress of when it was tabled, specifically to continue developing guidelines and methods for testing and investigation, and to develop evidence-based models and analysis of protective factors for BBV infection.
Outcomes
Laboratoryguidelinesweredevelopedcomprisingfivesections:1. principlesforoutbreakinvestigations2. specimenhandling,transportandstorage3. testingprotocolsforBBVinvestigations4. BBVgenotypingandsequencing5. laboratoryrequirementsforBBVinvestigations.
AdraftoftheBBVwebsitewasinstigatedwhichisaneducationalblogdesignedtoprovideanopenforumfordiscussiononcommunityissuesrelatedtoBBV,particularlyintheareaoflaboratorytesting.
SpecificBBVfacilitieswereidentifiedinfourmajorStatesformolecularepidemiologyinvestigationstudies.
DevelopmentofaneducationalwebsiteforhealthcareworkersandthecommunityonbasicinformationonBBVtransmission.Thiswasunderconstructionatthetimeofthereportat:http://www.bloodborneviruses.org.au/.
Recommendations 1. Continuedevelopmentofguidelinesandmethodsfortestingand
investigation,includingreversetranscriptionpolymerasechainreaction(RT-PCR)andsequencingprotocolsforthemolecularepidemiologyofBBVstomaintaintheseBBVfacilitiesasamodelofbestpracticeintheinvestigationandpreventionofBBVtransmission.
2. Developevidence-basedmodelsandanalysisofprotectivefactorsforBBVinfection.ThiswillresultinthedevelopmentofpracticalpoliciesforBBVtransmissionandpreventioninhealthcaresettings(liaisonhadalreadybeenestablishedwithPathWest,VictorianInfectiousDiseaseReferenceLaboratory[VIDRL]andNSWHealth).
Key Project Learning
ThemaindifficultywasmeetingdeadlinessetbytheAustralianGovernmentDepartmentofHealthandAgeingduetotheswineflupandemic.Mostvirologyexpertsandinfectiousdiseasescommitteeswereunavailableduetourgentissuesrelatedtothepandemic.
Follow on Initiatives and Projects
IntegrationofprotocolstoNationalBBVTestingPolicies.
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Risk Minimisation Riskminimisationinpathologypractice,fromcollectionofasampletoreportingtheresults,isparamounttothequalityuseofpathology.TheQualityUseofPathologyProgram(QUPP)hassoughttoaugmentthesolidbasisinriskminimisationbuiltbymultiplestakeholderssuchastheRoyalCollegeofPathologistsofAustralasia(RCPA),theRCPAQualityAssuranceProgramsPtyLtd(RCPAQAP)andtheNationalAssociationofTestingAuthorities(NATA)throughfiveprojects(Table3).Keyareasinriskminimisationincludeidentifyingearlywarningsignsthatcanidentifypoorlyperforminglaboratories,andassistingpathologylaboratoriestoidentify,measure,monitorandinvestigatepotentialoractualerrorswhichmayposeapotentialrisktopatientsafety.Theseprojectsalsohighlightedsomekeyprojectlearningsregardingstrategiestomonitor,measureandassesslaboratoryperformance,andhighlightedthesignificantchallengethatthemajorityoferrors(75%)inpathologyoccuroutsideoftheofthepathologylaboratories’control.Basedontheselearnings,areasforfutureconsiderationfromallreportssummarisedinthischapterinclude: Standardisekeydefinitionsandtermsforincidentmonitoringandreporting. Considerstrategiestoaddresstheissueoferrorsoccurringwhenanon-
pathologypersoncollectsapathologysample.[alt=“ThefollowingtableliststhefiveprojectnamesandgrantrecipientsundertheRiskMinimisationtheme”]
Project Name Grant Recipient/s
1 RCPA–QualityAssuranceProgramsKeyIndicatorProject(2004)
RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
2 PilotLaboratoryAssessmentandPeerReviewMechanismforPathologyKeyPerformanceIndicators(2007)
RCPAQAP
3 PerformanceMonitoringofExternalQualityAssurance(Current)
RCPAQAP
4 NATAFileAudit–RiskAnalysisofAssessmentNonConformancesIdentifiedinPathologyLaboratoryAssessmentAccreditation(Current)
NationalAssociationofTestingAuthorities(NATA)
5 KeyIncidentMonitoring&ManagementSystems(Current)
RCPAQAP
Table 3: Reports summarised for Risk Minimisation
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RCPA – Quality Assurance Programs Key Indicator Project (2004)
Description Thispilotprojectdevelopedamechanismtoidentifypoorlyperforminglaboratoriesonacontinuingbasis.Itarosefromrecommendation5.1oftheCorrsChambersWestgarthreporttitledThe Evaluation of Australian Pathology Laboratory Accreditation ArrangementsfortheAustralianGovernmentDepartmentofHealthandAgeing2002(CorrsChambersWestgarthLawyers)whichstates:
thattheDHAandtheHICseekthecooperationoftheRCPAQAPtoestablishexplicitexternalqualityassuranceperformancecriteria,initiallyinchemicalpathologyandgynaecologicalcytology,andamechanismfortheRCPAQAPtoidentifyrelativelypoorlyperforminglaboratories.
ThispilotwasthefirststageinthisprocessanddevelopedKeyPerformanceIndicators(KPIs)forchemicalpathologyandcytopathologythatcouldpotentiallybeusedtoidentifyanearlywarningalertsystemofpoorlaboratoryperformance.
Grant Recipient RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
Aims and Objectives
todeterminewhetherqualityassurancedatacanbeusedasanearlyindicatorofpoorlyperforminglaboratories
todevelopamodelorindicatorthatwillselectthelaboratoriesmostprobablyneedingreview
todeterminewhetherthesameorasimilarmodelorindicatorcanapplytoalldisciplinesofpathology.
These aims and objectives were achieved by this project.
Outcomes
ANationalPathologyAccreditationAdvisoryCouncil(NPAAC)SteeringCommitteewasestablishedtooverseetheproject,andtwoKPIworkinggroupsforeachdiscipline(chemicalpathologyandcytopathology)wereestablishedtoassisttheproject.
TheprojectgroupsandSteeringCommitteedeterminedthemethodologyforthepilotshouldbebasedona‘peerreviewprocess’ratherthana‘standards’approach.
Laboratorieswerereviewedindividuallytoensuretheirassessmentincludedonlyrelevantdatainthefollowingfourstepprocess:
1. Selectionofthepeergroupofthelaboratoryunderreview.2. Selectionoftheassessmentprocess.3. Processthelaboratory’sdata,theirpeersandrankingperformance.4. ConsolidatealldatatoobtainaKPI.
Itwasconsideredthataneedexistedtodevelopamoredetailedfeedbackofqualityassurance(QA)performancetohelplaboratoriesimprove.Itwas
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envisagedthePeerReviewCommittee(PRC)wouldaddressthisissue.Mostlaboratorieswouldalsobecomplementedongoodperformance,withthisprogramidentifyingpotentialproblemsearlier,butalsoprovidingpracticalandusefulguidancetoparticipants.
Chemical Pathology Program TheChemicalPathologyProgramcomparedalaboratory’sperformancewith
alllaboratoriesintheirpeergroup(thosethatdidthesametesting)andthenrankedtheirperformanceagainsteachother.
TheQualityAssuranceProgram(QAP)datawasmodeledusingvariousstatisticaltests.ThebesttooltodeveloptheKPIrankingacrossthewholelaboratoryforallanalyteswasconsideredtobetheCoefficientofVariation(CV%).
Anumberofkey/criticalanalyteswereidentifiedandrankedforeachlaboratoryusing‘TotalError’.
Alllaboratorieswouldreceiveareportoftheirperformance. ThesetofassessmentcriteriarecommendedforChemicalPathologywas:
o aKPI<0.05o aparticipationrateintheQAPof<80%o alateresultrateof>10%o aresultcorrectionrateof>5%
IfthelaboratorymetthesecriteriatheywouldbereferredtothePRCtoassessiftherewasaproblem.
Theprogramrequiredsomefurtherminorrefinements,butwasanticipatedtobeimplementedonatrialbasisin2005.
Cytopathology KPI Program AsimilarprocesstotheChemicalPathologyProgramwasdevelopedwith
eachlaboratoryrankedagainstitspeers. ItwasonlymodeledinGynaecologicalCytopathology,andrequiredfurther
refinementoverthefollowing12months. TherecommendedassessmentcriteriaforCytopathologylaboratorieswas:
o aKPIrankinthelowest10thpercentileoftheirpeergroupo morethantwomajorerrorsinanyprogramo lessthan75%ofresultssubmittedo morethan50%ofresultssubmittedafterthedeadline.
IfalaboratorywasidentifiedasfallinginsidetheassessmentcutoffrangestheywouldbereferredtoaPRC.
Fourscoreswerecreatedforrankinglaboratoriesdeterminedfromasetof20slides.Adiagnosiswassuppliedbythelaboratoryforeachslidewhichwasscoreddependingonwhetherthetargetresponse(10),anacceptableresponse(9)anunacceptableresponse(4)oramajorerror(-1)wasreported.
Reviewofthevalueofthescoresmayberequiredtoensuretheyprovidedtherequireddiscriminationofperformance.Furtherattentionmayberequiredintheclassificationofacceptable,unacceptableresponsesandthoseconsideredmajorerrors.
Itwassuggestedthatascytopathologywouldnothavesufficientdataforanalysisinasix-monthtimeframe,thatrolling12monthdatabereviewedeverysixmonths.
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Theseguidelineswillbeextendedandmodifiedasrequiredfornon-gynaecologicalcytology.
Peer Review Committee ThePeerReviewCommittee(PRC)wastobeestablishedforeachdiscipline
andwouldformasub-committeeoftheMedicalTestingAccreditationAdvisoryCommittee(MTAAC)oftheNationalAssociationofTestingAuthorities(NATA).
ThePRCwastobemadeupof:o twoRCPAFellowsfromtherelevantdisciplineso twootherrelevantprofessionalso tworepresentativesfromtherelevantQAOffice,onebeingthecurrent
chairpersono oneNATArepresentativeo oneGovernmentrepresentative.
ThePRC’sstructurewastobetrialedinthenextstageofthePilotProject,withnopecuniaryactiontakenuntiltheprocesshadbeenagreedtobytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA).
ItwastheresponsibilityofthePRCtodetermineifthelaboratoriesreferredtoitwereperformingbadly,oriftheywereatthebottomofaveryhighperforminggroupoflaboratories.IftherewasaconcerntheywouldbereferredtoNATAforanaccreditationvisitordeskaudit.
Ifalaboratoryisenrolledinanon-RCPAQAPqualityassuranceprogram,theyshouldstillberequiredtosubmitreportssimilartothoseprovidedbyRCPAQAPPtyLtdtotheMTAACPeerReviewSubcommittees.
Findings
Thereareteststhataregenerallydonewellbyalllaboratoriesandteststhatarenotdonewellbyanylaboratories.Thisisduetothedevelopmentstageorlevelofthetest.Poorperformanceofalaboratoryshouldbebasedonthelaboratory,andnotontheanalyte.Basedonthisinformation,laboratoryperformanceshouldbemeasuredbytheteststhataregenerallyperformedwellbyalllaboratories.
KPIsareatooltoassistinidentifyinglaboratoriesthatmayneedreview.Nocomputerprogramhasthesubtletytounerringlyindicateamandatorylaboratoryreview.Thereisacceptancethatevenafterthepeerreviewprocesshadsuggestedtherewasaproblem,theKPIwouldonlybeusedasaflagtonotifyNATAthatthelaboratoryrequiredsomeformofreview,whetherasaformalvisit,paperauditorsomewhereinbetween.
TheChemicalPathologyqualityassuranceprogram(QAP)analysisandreportappearedtohaveahighlevelofacceptancebytheprofessionandparticipants.
TheCytopathologyKPIProgramwasmoredifficulttodevelopbecauseitisaqualitative(opinion-based)specialtyratherthanaquantitative(measurable)specialty.
TheimplementationoftheCytopathologyKPIProgramrequiredaculturalshiftamongstcytologists,andmayrequireareviewoftheQAP.PreviousQAPshavebeenviewedasa“testandteach”ratherthanmeasuringperformance.
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Duetothesmallnumberofcytologistsinanylaboratory,KPItestingmaybeviewedasanindividualassessmentratherthanalaboratoryassessment.Consideringthe‘pilot’natureoftheprogram,thishascausedconcernswithsomelaboratories.
Cytopathologysuffersfromthedifficultiesofprovidingsuitabletestmaterialsinthequantitiesandvarietythatcreateequitableassessmentamonglaboratoriesduetothequalitativenatureofthetestingprocess.Someofthedifficultiesmayberectifiedinthefuturewiththeintroductionofvirtualmicroscopy.
CarefulinterpretationoftheKPIdataisessential.Poorperformancemustbecomprehensivelyassessedanditispossiblethatinsomecasesthepoorestperformersmaystillbesatisfactoryforpatientcare.
Recommendations 1. Extendtheprojecttootherdisciplines,withblood-bankingthenext
recommendedareatoundergothisprocess.2. Fundingoptionsbeyondthepilotprogramshouldbeinvestigated.3. Educatetheprofessionabouttheprojectandfurtherrefinementovertimeof
theKPIprocess.4. InformotherQAprovidersofthisinitiative.5. Furtherstudieswouldbeinvaluableastheprocessproceeds,particularlyfor:
a. ‘critical’analytesb. sizeoflaboratoryc. methodstoidentify‘gamingandcollusion’d. year-to-yearconsistency.
6. Finalisesoftwaredevelopmentondatafrom2002onwards.7. ProcessanddistributeJanuarytoJune2004data.
Key Project Learnings
Itwasfeltthatwhilegraphicalreportingwasinitiallyusefulinrankinglaboratories,theKPIplotshouldnotbereportedbacktothelaboratoriestoavoidthepotentialtopromotetheir‘ranking’forcommercialadvantage.Asthepurposeisprimarilytoidentifypotentiallypoorlyperforminglaboratories,theaddedinformationregardingrelativerankingswasconsideredirrelevantandmayraiseadditionalconcerns.
Determiningthecut-offpointfor‘poorlyperforming’laboratorieswasnotaneasytask.Theyweresubjectedtoseveralmodelsandseveralroundsofevaluation.
TheRCPAQAPneededtoobtainlegaladviceregardingthefeasibilityofawaiverwithrespecttoliabilityforlaboratoriesthatsignedupforparticipationinthisproject.ThisisbecauselaboratorieswhoseKPIreportsweresubmittedtothePRC,followedbyasubsequentinspectionbyNATAandanyotherstepsintheprocess,mayotherwiseresorttosuingtheRCPAQAPforeconomicloss.
Follow on Initiatives and Projects PilotLaboratoryAssessmentandPeerReviewMechanismforPathologyKeyPerformanceIndicators(2007).
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Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007)
Description Thisprojectarosefromrecommendation5.1oftheCorrsChambersWestgarthreporttitledThe Evaluation of Australian Pathology Laboratory Accreditation ArrangementsfortheAustralianGovernmentDepartmentofHealthandAgeing2002(CorrsChambersWestgarthLawyers)whichstates:
thattheDHAandtheHICseekthecooperationoftheRCPAQAPtoestablishexplicitexternalqualityassuranceperformancecriteria,initiallyinchemicalpathologyandgynaecologicalcytology,andamechanismfortheRCPAQAPtoidentifyrelativelypoorlyperforminglaboratories.
ThefirststageofthisprojectdevelopedKeyPerformanceIndicators(KPIs)forChemicalPathologyandCytopathologythatcouldpotentiallybeusedtoidentifyanearlywarningalertsystemofpoorlaboratoryperformance.ItwasidentifiedthatafurtherstepwasrequiredinthedevelopmentofKPIstoassessiftheywereavalidtoolforthispurpose.Thisresultedintheproject’ssecondstageasrepresentedbythisproject.
Grant Recipient RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
Aims and Objectives
establishmentofPeerReviewCommittees(PRCs)forChemicalPathologyandgynaecologicalCytopathology
pilotextensionoftheKPIassessmentandreviewprocessasdevelopedintheinitialproject
addresstheissueoftheNationalPathologyAccreditationAdvisoryCouncil(NPAAC)producingastandardorotherdocumenttoprovidelegislativebackingtotheprocess
fundingoptionfortheKPIassessmentandreviewprocessinthelongtermtobeinvestigated
theRCPAQAPneedstoobtainlegaladviceregardingthefeasibilityofawaiverwithrespecttoliabilityforlaboratoriesthatsignupforparticipation
educationoflaboratoryparticipantsontheKPIassessmentandreviewprocess
potentialfurtherrefinementoftheKPIsisrecognisedasbeingalogicaldevelopmentoftheprogramandbeneficialtotheimprovementofdiagnosticcapabilities.
These aims and objectives were achieved by this project.
Outcome
Thisprojectdemonstratedtheneedforanappropriateprofessionalreviewoftheproposedmechanismsforthedevelopmentofaneffectiveearlywarningsystemtodetectpotentiallypoorlyperforminglaboratories.
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Findings
TheresultsofthepilotprojecttoevaluatetheuseofKPIstoidentifypoorlyperforminglaboratorieshasmeanttheSteeringCommitteecouldnotrecommendtheuseofKPIsasaformalmonitoringprocessforpoorlyperforminglaboratoriesaspartofNPAAC.
TheChemicalPathologyKPIshavebeenidentifiedasausefulinternalqualitytoolforlaboratoriestouse.
ThepoweroftheKPImethodologyisverydependentontheamountofdatathatcanbeanalysed,andasaconsequence,theKPIshavebeenmoreusefulinChemicalPathologythaninCytopathology.
TheinformationtohandsuggeststhatKPIsandthePRCprocesscanidentifylaboratorieswithpoorExternalQualityAssessment(EQA)performance,butthisdoesnotnecessarilyequatetopoorratingsatanon-siteassessment.
ThelowestKPIlaboratorieswerenotdistinguishedbymoreadverseassessmentoutcomeswhencomparedwiththehighestKPIgroup.
ThemethodologiesusedsuggestedthecurrentKPIswerenotasensitivetestofoveralllaboratoryperformancewhencomparedtoassessmentfindings.
ThecorrelationoftheKPIsandNationalAssociationofTestingAuthorities(NATA)assessmentsdidnotsupporttheiruseasan‘earlywarningsystem.’
TheKPIsascalculatedforthisprojectwerebasedsolelyonqualityassuranceprogram(QAP)performance.Theirnameinfersthiscorrelateswithactuallaboratoryperformance,however,thisdoesnotappeartobethecase.
Recommendations 1. ThefrequencyoftheKPIreviewforChemicalPathologyshouldbeeverysix
months.2. Cytopathologydoesnothavesufficientdataforasix-monthreview,soit
shouldhaveanoverlapping12monthrevieweverysixmonths.3. KPIsarenotavalidtooltouseforidentifyingpoorlyperforming
GynaecologicalCytopathologyLaboratories,andasaconsequencetheSteeringCommitteerecommendsthattheyNOTbeimplementedintheexistingformat.
4. TheKPIsforChemicalPathologyappearedtobeofsomeuseinidentifyingpoorlyperforminglaboratoriesandarewellacceptedbylaboratoriesasausefulinternalqualitytool.However,duetothepoorcorrelationbetweenlaboratoriesknowntobepoorlyperformingandtheKPI,theSteeringCommitteecouldNOTrecommendtheintroductionofKPIsinChemicalPathologyasaformaltoolenshrinedinNPAACStandardstohelpidentifypoorlyperforminglaboratories.However,becauseoftheusefulnessoftheKPIinChemistrytoevaluateperformancebasedonqualityassurance(QA)data,andpotentiallyusefulinrankinglaboratoriesoverallperformance,theRCPAQAPwillcontinueproducingtheKPIsforChemicalPathologyandthiswillbeincludedwithintheservicesitofferstoitsparticipants.
5. TheSteeringCommitteeconsidereditappropriatetocontinueaPeerReviewMechanismforChemistryonatrialbasis.
6. TheSteeringCommitteeconsidereddevelopingKPIsinBloodTransfusionsonapilotbasisasuseful.
7. QAPdatainCytologyexpressedasKPIshasnotprovenusefulasapredictorof“poorlyperforming”laboratories,althoughalargenumberofmajorerrors(e.g.greaterthanthree)inaQAPmaystillbeausefultriggerforreview.
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8. ExaminationoftherelationshipofPerformanceMeasurestoNATAAssessmentfindingsshouldbethesubjectofafurtherstudy.
9. TheroleandmembershipofthePRCanditsTermsofReferenceneedtobeexploredfurther.
10. LegaladvicetotheRCPAQAPregardingfeasibilityofawaiverwithrespecttoliabilityforlaboratoriesthatsignedupforparticipationincludedtherecommendationthatidentifyinginformationneverbereleasedtothePRCingeneral,butonlytoNATA.TheyalsoadvisedseekingalegalagreementwithNATAtoensurethatNATAneverdisclosestheidentifyinginformationtoathirdparty,andthattheiractionsbelimitedtoanacceleratedreviewofthelaboratoryinquestion.
11. Ongoingfundingforanyfurtherprojectsneedstobeconsidered.12. PotentialfurtherrefinementoftheKPIswasrecognisedasbeingalogical
developmentoftheprogramandbeneficialtotheimprovementofdiagnosticcapabilities.
13. TheworkundertakenatPacificLaboratoryMedicineServices(PaLMs)regardingKPIsforquantitativepathologyworkcouldformthebasisforfurtheranalysisoftheirfindingstoprovidethescientificcommunitywithaclearunderstandingofwhichtestsneedtobeconcentratedonintermsoffurtherdevelopmentandqualityimprovement.
Key Project Learning
ThereweredelayscompletingtheprojectrelatedtoKPIsoftwareandtheworkforcecrisisinpathologymeaningthetimepathologistscouldgivetothisprojectonavoluntarybasiswasrestricted.ItalsosometimestooklongperiodsoftimetogettheCommitteetogethertoreviewdatawhichalsodelayedtheproject.
Follow on Initiatives and Projects
PerformanceMonitoringofExternalQualityAssurance(Current) NATAFileAudit–RiskAnalysisofAssessmentNonConformancesIdentified
inPathologyLaboratoryAssessmentAccreditation(Current).
Performance Monitoring of External Quality Assurance (Current)
Description Thisprojectisinvestigatingifanearlywarningsystemcanbeestablishedtohelpminimiserisktopatientsandassistlaboratoriesinaddressingexternalqualityassurance(EQA)concernsearly.TheRoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)previouslyranaRCPA–QualityAssuranceProgramsKeyIndicatorProjecttrialwhichwillberevisitedforchemicalpathology(datahadbeencollectedoverfouryears).KPIsarenowbeingdevelopedforotherpathologydisciplines,notablyanatomicalpathologyandtransfusionserology,andevaluatedasindicators.ThisprojectwillharmonisewithcurrentKeyIncidentMonitory&ManagementSystems(KIMMS)initiatives.
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Grant Recipient RCPAQAP
Aim
todeveloppathologylaboratoryperformancefromanumberofperspectives.
Objectives
toexaminepathologylaboratoryperformancefromanumberofperspectives toestablishaworkingpartywiththeTherapeuticGoodsAdministration
(TGA)todevelopwaystoidentifysub-standardtestsandkitsthatcanhaveadirecteffectonpathologylaboratoryperformance
toreviewfouryearsofKPIdataandcorrelatewithNationalAssociationofTestingAuthorities(NATA)accreditationvisits
toestablishKPIsystemsanddevelopsoftwarefortransfusionserologyandanatomicalpathology
tosetbenchmarksforeachKPIdiscipline todevelopnovelprotocolstouseongoingEQAresultstomonitor
performance toestablishmechanismstouseEQAdatatohelpmonitorqualityoftests.This project is current and the aim and objectives are in the process of being achieved.
Outcomes AsatDecember2011thefollowinghadbeenachieved: KPIsystemsandbenchmarksforacceptableperformancehadbeen
developedandfinalisedfortransfusionmedicine,cytopathologyandanatomicalpathology
asecondroundconsultationphaseontheproject’sdraftframeworkhadbeencompleted
softwaredevelopmentincludeddefinitionofoverallprojectspecificationdocumentation,scopingofanatomical,transfusionandcytopathologyprogramspecificationsandproductionofprojectdesigndocumentation
finalisationofthedesignofPerformanceSummaryReportsforanatomicalpathology,cytopathologyandtransfusionmedicine
acumulativescorefortransfusionmedicinedevelopedtoreflectperformanceoversixsurveys
theRCPAQAPiscurrentlyexploringtheissueofsendingparticipantreportsdirectlytoNATA.
NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current)
Description TheNationalAssociationofTestingAuthorities(NATA)isconductingananalysisofnon-conformancesidentifiedduringitsassessmentsofpathologylaboratoriesagainsttheaccreditationmaterialsoverthepastthreetosixyears.Thisproject
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complementsotherQUPPfundedinitiatives,suchasthePerformanceMonitoringofExternalQualityAssuranceprojects,aspartofthepathologyriskminimisationstrategiestoimprovepatientsafetyfollowingthe2009Budgetinitiativetocontinuethedevelopmentofkeyperformanceindicatorsandotherriskidentifiersinpathologyserviceprovision.
Grant Recipient NATA
Aims and Objectives
toidentifycommonissuesandtrendsinpathologylaboratoryassessment toestablishtrendsandpatternsinpoorlyperformingpathologylaboratories toexaminecorrectiveactionsthatarecurrentlybeingundertakenby
laboratoriestoaddressdeficienciesdocumentedinassessmentreports todevelopabasistoarticulatestrategiesthatwilladdresscausesofpoor
performance.This project is current and these aims and objectives are in the process of being achieved.
Outcome
NATAhasdevelopedriskmatricestoassistwiththeirexaminationofcommonissuesandtrendsinpoorlyperforminglaboratories,andiscontinuingtoprogresstheirreviewoffiles.
Key Incident Monitoring & Management Systems (Current)
Description TheKeyIncidentMonitoringandManagementSystems(KIMMS)ofPathologyLaboratoriesassistpathologylaboratoriestoidentify,measure,monitorandinvestigateincidentsinpathologywhichhavethepotentialtocauseharm,andinvestigatetherootcauseoftheseincidentssotheyareminimised,whichinturnwillminimisepotentialharmtopatients.Italsoaddressesthequalityassurance(QA)issuesintheareasofbothanalyticalandnon-analyticalerrors.Thepre-analyticalphasefocusesonidentification/labelingofthesampleandthesamplerejectionrates,whilethepost-analyticaloftestingexaminesresultscorrectedbecauseoflaboratoryerrorandresultsreportedtothewrongdoctor.Theprojectanalysedthe2007-2008KIMMSpilotdatacollection.
Grant Recipient RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
Objectives
toassistlaboratoriestomeasureandmonitorincidentsinthepre-andpost-analyticalphasesinthepathologyrequest-test-reportcycle
toprovidedatacollectionandreportinginfourareas:1. pre-andpost-analyticalphases2. howeachincidentwasidentified(bythelaboratoryorbyacomplaint)3. theoutcomeoftheincident(actualorpotentialpatientharm)
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4. overallincidentrateasapercentageofworkloadeachquarter toraiseawarenessofsafeworkpracticeswhichwillinturnreduceerrors
andincreasepatientsafety toreducethenumberofincidentsinpathologylaboratorieswhichwill
directlyimpactonpatientsafety.These objectives were achieved by this project, although the final objective is a longer-term deliverable.
Outcomes
TheRCPAQAPmadeasubmissionunderPartVCoftheAustralianHealthInsuranceAct1973fortheKIMMSprogramtobeformallydeclaredasaQualityActivitytoprotectlaboratoriesfromlitigationduetodatacollectiononadverseincidents,especiallythosewhovoluntarilydisclosethisinformation.
TheRCPAQAPhasemployedthreeInformationTechnology(IT)stafftomovesoftwaredevelopmentinhouse.ThenewsoftwaredevelopedwillbehousedonRCPAQAPserversunderRCPAQAPcontrol,andwillbearepositoryfortheaggregatedKIMMSdata.
KIMMSdatawillraiseawarenessofunsafeworkpracticesandprovideinformationtotherelevantsectionsofthemedicalcommunitysotargetedsolutionscanbeimplementedtoimprovepatientsafety.
KIMMSwillintroducegradedclassificationofpatientharmin2010. KIMMSdatacanbeutilisedtosetachievablenationalbenchmarksforgood
pathologypractice.
Findings
KIMMSdataconfirmedtheirqualitysystemcapturesmostincidents(97%)allowingthepathologyservicetocorrecttheproblembeforetheycausepatientharm.
KIMMS2007&2008pilotshowedthatbetween70-80%ofsamplemisidentificationproblemswereduetospecimensnotmeetingminimumlabelingrequirementofprovidingtwoidentifiers(e.g.nameanddateofbirth).
Theoverallincidentratewas0.7%in2007(fourthcycle)and0.9%in2008.Althoughtheseratesarelow,thenumbers(114,000incidentsannuallyfromonly24laboratoriesisasmallfractionofAustralianpathology)indicatethestaggeringresourcesusedtostopnon-laboratoryerrorsaffectingpatientsafety.Thesesimpleerrorsareallpreventable.
Overall,pre-analyticalincidentsaccountedforthemajorityofincidents(85-90%in2008)whichisconsistentwiththeliterature.
Post-analyticalphaseoftestingincidentrateswere0.01%ofallaccessions.Theseincluderesultsretractedduetoanerrorbythelaboratoryandthenre-issued,andverylowlevelswhereresultsweresenttothewrongdoctor.
Theincidentratesinthepre-andpost-analyticalphaseoftestingisunder-reportedasmanylaboratoriesdonotcurrentlyrecordtheseincidentsinawaythatallowseasyconsolidatedreporting.
Theabsoluterateatwhichpre-analyticalproblemsoccurredexceededtherateatwhichanalyticalproblemsoccurredasmeasuredinthedetailsframeworkforqualityassuranceprograms(QAPs).
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Thereisaneedtoaddresspoorsamplecollectiontechnique. Incidentratesincreasedduringthisstudyasparticipantsimproveddata
extractionandcapturetechniques,butshouldeventuallystarttofallas:o pathologyservicesimprovedtheirprocesseso KIMMSraisedawarenessofproblemso varioussectionsofthemedicalcommunityareeducatedinsafework
practices. Laboratoryinformationsystems(LIS)neededtobeconfiguredtocapturethe
dataatthetimeofentryofpatientinformationintothesystem.
Recommendations 1. Standardisingkeydefinitionsandtermsforincidentmonitoringand
reportingisanissuethatneedstobeaddressedtoaccommodatecomparisonofdata.
2. ContactLISproviderstodiscussincorporatingKIMMSdatarequirementsintofutureversionsofLISsoftware.
Key Project Learnings
Thesignificantchallengethatpathologyservicesexperienceisthemajorityoferrors(75%)arenotcausedbypathology.Mostoccurwhenasampleiscollectedbyanon-pathologypersonandareduetopatientmisidentification,incorrectsamplecollectionandthesamplebeingmislabeled.Theseinappropriatepracticescanjeopardisepatientsafety,particularlyforirreplaceablesamples(neonates,biopsymaterialandspinalfluids)wherethelaboratoryhasnooptionbuttoprocessthesampleandprovidea(qualified)result.
ManyparticipantsinthepilotstudydislikedtheKIMMSclassificationofactualandpotentialharmtopatients.
Feedbacksuggestedamoreaccuratemeasureforsamplerecollectionswouldbesamplerejectionsaslaboratoriescouldcapturethisdata.
Evaluatingtheoutcomeofanincidentcausedconfusionandconcernformanyparticipants.
ThepilotphaseofthisprojecthighlightedthedifficultylaboratoriesexperiencedinextractingorcollectingofdatafromcurrentLISwhicharenotsetuptorecordandreport/extractthisdata.A2006questionnairesenttoallpilotparticipantshighlightedthat45%orparticipantscollectedincidentdatamanually(inanexercisebook)andafurther30%recordeddatainaspreadsheetoradatabase.
Bothpilotdataandfeedbackindicatedthatpathologyserviceswerenotsystematicallycollectingdataonincidents,whileotherswhodowerenotdoingsoinamannerthatallowedcomparisonorpeerreview.
Follow on Initiatives and Projects
PromotionofsuccessfulstrategiesontheRCPAQAPwebsite.
Areas for Future Consideration
Standardisekeydefinitionsandtermsforincidentmonitoringandreporting. Considerstrategiestoaddresstheissueoferrorsoccurringwhenanon-
pathologypersoncollectsapathologysample.
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Quality Assurance and Capacity – New Technology Technologyisbecominganintegralpartofhealthcareandhasthecapacitytoaugmentdiagnosticcapabilitiesatboththepointofcare(PointofCareTesting[PoCT])andinthelaboratory/hospitalsetting.Qualityassurance(QA)issuesareparamounttoensurenewtechnologywillproducereliableresults,especiallyintheemergingareasofPoCTandgenetics.Ensuringtechnologyalsohasthecapacitytodeliverqualityoutcomesintothefuturebeforeaninvestmentismadeisalsoanongoingissueinhealthcare.TheQualityUseofPathologyProgram(QUPP)enabledprojectstodevelop,defineandeducatestakeholdersaboutthequalityassuranceandcapacityofnewtechnology.Eightprojects(Table4)coveredareasfromgeneticstoPoCT,withamajorissuearisingbeingQAissuesassociatedwithPoCT.TheemergingareaofgeneticswasalsotargetedwithprojectsthatsoughttodefineandinformstakeholdersaboutbestpracticeandQAissuesinthisarea.PoCTandgeneticsarealsodynamicareaswithinformationandcapabilityincreasingrapidly,sometimesfrommonthtomonth.Theseareasunderpintheareasforfutureconsiderationincluding: FurtherpossibleworkbytheGeneticsWorkingPartysetupunderthe
PathologyFundingAgreement. InvestigatetheframeworkforPoCTinGeneralPracticerecommendedbythe
Point-of-Care Testing in General Practice Trial (http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pathology-poctt-index.htm).
InvestigateanddefineQAissuesforPoCT.[alt=“ThefollowingtableliststheeightprojectnamesandgrantrecipientsundertheQualityAssuranceandCapacity–NewTechnologytheme”] Project Name Grant Recipient/s 1 VirtualMicroscope(2005) RoyalCollegeofPathologistsof
Australasia(RCPA)2 HighResolutionScanningMicroscopyforQuality
AssuranceandEducationalApplications(2009)RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
3 DevelopmentofaQualityAssuranceModuleforHumanPapillomaVirusTesting(2008)
RCPAQAP
4 PreparingforGenomicMedicine:NationalAuditandDevelopmentofaBestPracticeApproach(2009)
RCPA
5 Policies,ProceduresandGuidelinesforPoint-of-CareTesting(2011)
RCPAQAP
6 PoCTTraining,Certification,SupportandSkillMaintenanceProgram(AustralianPoCTPractitionersNetwork–APPN)(Current)
AustralasianAssociationofClinicalBiochemists(AACB)
7 EstablishmentofaMolecularGeneticsQualityAssuranceProgram(Current)
RCPAQAP
8 MAWSON–AnOnlineRepositoryofGeneticDatatoAidReportingofMedicalGeneticTests(Current)
UniversityofSouthAustralia
Table 4: Reports summarised for Quality Assurance and Capacity – New Technology
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Virtual Microscope (2005)
Description TheVirtualMicroscope(VM)isacomputersystemconsistingofbothsoftwareandhardwareforscanningmicroscopicimagesofcells,tissuesandbodyfluidsandconvertingthemintoadigitalimage.ThetechnologyallowstheimagestobetransferredtoaCDandtotheInternet,andisparticularlybeneficialforqualityassurance,trainingandeducationalpurposes.TheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)providedfundingtotheRoyalCollegeofPathologistsofAustralasia(RCPA)forthisprojectandtheVMwasinstalledon2August2004.Theprojecttimeframewas1March2004to31January2005,withregularupdatessubmittedforthelifeoftheassetuntil2009.
Grant Recipient RCPA
Aims and Objectives
tointroducevirtualmicroscopetechnologyasameansofdeliveringhighqualityimagestolaboratoriesintheRoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)andotherqualityassuranceprograms
tousevirtualmicroscopytechnologytodevelopeducationpackagesforTraineesandFellows
tocollaboratewithUniversityMedicalSchoolsandotherpathologyorganisationstoprovidedigitalimagesforeducationalprogramstobenefitregistrars,medicalpractitionersandmedicalscientists
tocoordinatetheuseofthevirtualmicroscopytechnologyforotherpathologyrelatedorganisationswithqualityassuranceprograms.
These aims and objectives were achieved by this project.
Outcomes
Pilotsurveyswereundertakenin2007and2009,withCDdeliveryofimagesratedhigherthanonlinedelivery.
SurveyresultswerepresentedasaposterattheInternationalSocietyforLaboratoryHematology(ISLH)conferenceinMay2009.
AscanningservicewasestablishedbytheRCPAHaematologyQualityAssuranceProgram(QAP)forclientswithinandoutsidetheRCPA.
CandidatesfortheRCPAHaematologyFellowshipparticipatedinmockexaminationsessionsforthepreparationoftheirrigorousmorphologyexamination.
SlidescanninghasbeenprovidedtotheUniversityofTasmaniafortheireducationmaterials.
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Findings
VirtualmicroscopycannotyetcompletelyreplaceglassslidesurveysbecausesomelaboratorieshavedifficultieswithdownloadingduetorestrictivepoliciesforsoftwareinstallationorslowInternetconnection.However,itisausefuladjuncttothecurrentRCPAQAPglassslidehaematologymorphologyprogramwithparticipantschoosingtoreceivethedigitalimagesonlineoronCDs.
Highresolutionvirtualslidesofbloodandbonemarrowsmearsarepracticalalternativestoglassslidesetsforeducationandtraininginhaematologymorphology.
Key Project Learning
Onechallengewasongoingtechnicalproblemswiththeoriginalsystem.ItwascompletelyreplacedbythemanufacturerinMarch2006underthewarrantyagreement.
Follow on Initiatives and Projects HighResolutionScanningMicroscopyforQualityAssuranceandEducationalApplications(2009).
High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009)
Description ThisprojectsoughttoexpandoftheuseoftheVirtualMicroscopepurchasedin2004fortheVirtualMicroscopeprojectbyprovidinghighqualitydigitalslidesforeducation,trainingandqualityassuranceactivities.
Grant Recipient RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
Aims and Objectives
toestablishakeyresourceindigitalmicroscopy toprovidehighqualitydigitalimagesforqualityassurance,educationand
trainingpurposes.These aims and objectives were achieved by this project.
Outcomes
AlldiagnosticmodulesoftheAnatomicalPathologyQualityAssuranceProgramcontainedsomevirtualmicroscopeimagesin2007.
Twonewmoduleswereestablishedusingvirtualmicroscopeimagesonly. VirtualmicroscopeimageshavebeenpreparedonbehalfofTheAustralian
AnimalProficiencyStandardsProgramforinclusionintheirqualityassuranceprogram.
AtrainingprogramwasdevelopedtorespondtonewHER2positivebreastcancertargetedtherapy.
Aninitialpilotprogramusingweb-basedsoftwarewasundertakenin2006consistingofanumberofquestionsanddigitalimagesforinterpretation.
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SlidesfromcompositeblockswereprovidedforlaboratorytestingwitheachindividualsubmittinginterpretationoftheHER2CISHstainingthroughDigitalSlidebox.
Approximately3500slideshavebeenscannedsince18March2008foreducationandtrainingpurposes.
Variousorganisationsandinstitutionshaveusedtheslidescanningtechnologyforslideseminarsandeducationalpurposes.AprojectonbehalfofAnimalHealthAustraliahasdigitalisedalargereferencesetofveterinaryslidesfortheeducationofveterinarypathologists.
VirtualimagesofglassslidescaseswereputontheAnatomicalPathologywebsiteforparticipantstoreviewwhenrespondingtosurveysandreviewingresults.
SlidesfromtheCytopathologyQAPhavebeenscannedforpilotsurveysintheirprogram.
AlargecollectionofslidesfromthePrinceofWalesMedicalResearchInstitutehasbeenscannedfortheproductionofratbrainatlases.
Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008)
Description Theprojectsoughttodevelopaqualityassuranceprogram(QAP)forthetestingofhumanpapillomavirus(HPV)DNAbypathologylaboratories.Twopilotstudieswereproposed,butonlytheresultsofPilotStudyOnewereincludedinthisreport.
Grant Recipient RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
Aims and Objectives
toestablishthebestmaterialandpreparationmethodforspecimenstoissuetolaboratoriesasameansofassessinglaboratorytestingperformanceforHPVDNA
topreparetwopilotstudiessothatthemostsuitablemediumforHPVDNAspecimenscouldbefullyevaluated(DrySwabandPreservCytspecimens)
toimplementstabilitystudiesduringthepilotstudystage toenlist20participantsforeachpilotstudywhowerecommittedto
providingfeedbackandsuggestionstoimprovewitheachsurvey toenlistfurthermembersoftheHPVDNAcommitteesothateachstageof
theprocessindevelopingaqualityassurance(QA)modulecouldbefullyevaluated.
todevelopanappropriatequestionnaireandwebsitedataentryscreensthatwouldbemodified/adjustedinresponsetoparticipantfeedback/suggestions.
Most aims and objectives were achieved by this project, although it did not specifically address the best material and preparation method for specimens to
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issue to laboratories as per the first point above. Stability studies to confirm that shipping specimens at ambient temperature did not affect the integrity of the specimens were also ongoing.
Outcomes Feedbackforthewebsitedataentryincluded: Thenumberofdigitsforenteringnumbersneededtobeextended(thiswas
fixedimmediately). Therewassomeconfusionwiththeunitoptionsavailableandbeingusedby
participants.ThiswasreflectedintheresultsdownloadedattheconclusionofthesurveyandwouldbeaddressedforPilotStudyTwo.
TheuseofmultipleparticipantnumbersforthosereceivingboththePreservCytandDrySwabspecimenscausedsomeconfusion.ThisisuniquetothepilotstudiesandwillbesimplifiedoncethespecimentypehasbeendecidedandimplementedafterPilotStudyOne.
Findings
PilotStudyOneshowedtheutilityofaqualityassuranceprogramforthetestingofHPVDNA.
ThenumberofparticipantstestingtheDrySwabpanelwaslowerthanforthePreservCytspecimensanddirectcomparisonbetweentestingthesesamplesmaynotbeappropriate.
ThereturnedresultssuggestthereisgreatervariabilityamongparticipantsusingamplificationmethodsthanthoseusingHybridCapture.
Recommendations 1. PossiblesurveyresultscouldbeusedduringthenextrevisionofNational
PathologyAccreditationAdvisoryCouncil(NPAAC)Guidelines.2. Theformulationofasecondpilotstudyshouldcontinuetakingintoaccount
thecopynumberevaluatedandinconsistenciesnotedbetweenparticipantswithvaluesandunitsreportedfortheHybridCapturemethodology.
Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)
Description Thisprojectinvolvedanauditofgenetictestingactivity,developmentofanonlinecatalogueofgenetestsandgeneticlaboratoriestoassistclinicians,developmentofguidelinesforreportingofgeneticteststomedicalpractitionersandanationalevaluationofmoleculargeneticqualityassuranceprograms(QAPs)inAustralia.
Grant Recipient RoyalCollegeofPathologistsofAustralasia(RCPA)
Aims and Objectives
tointegratecurrentgeneticentriesintheRCPAManualOnlinewiththenewlistingbeingdeveloped
tocompletethereviewofsubmitteddatafromlaboratories
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toconductacomprehensivetestrunusingsubmitteddatafromlaboratories toreviewandeditsubmittedown-databyeachlaboratory thereviewofresourcesbytheRCPAManualOnlineeditorialcommittee.These aims and objectives were achieved by this project.
Outcomes
Thefirstnationalsurveyofgenetictestingactivityacrossallserviceprovidersandregionsthatcaninformpolicydecisions.
Thefirstnationalonlineandupdatedcatalogueofgenetestsandgeneticlaboratoriestoassistclinicianstofindwhichlaboratoryisofferingatest.
Thefirstnationalguidelinesforthereportingofgeneticteststomedicalpractitioners,includingastructureforsynopticreporting.ThisisbeingincorporatedintotherevisionoftherelevantNationalPathologyAccreditationAdvisoryCouncil(NPAAC)standards.
Thefirstinternationalstandarddealingwithsamplerequirementsingenetictesting.
Follow on Initiatives and Projects
The catalogue of genes, genetic tests and genetic laboratories was established as a component within the RCPAManualTransformationProject(2010).
Areas for Future Consideration
FurtherpossibleworkbytheGeneticsWorkingPartysetupunderthePathologyFundingAgreement.
Policies, Procedures and Guidelines for Point-of-Care Testing (2011)
Description Thisprojectwasacomprehensivereviewandanalysisofnationalandinternationalpoint-of-caretesting(PoCT)qualitymanagementregulationpoliciesandprotocols.
Grant Recipient RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
Aims and Objectives
toreviewthecurrentregulatoryrequirementsandprofessionalopinionwithregardtotheimplementationandqualitymanagementofPoCT
tosummarisecurrentlyavailableinternationalstandards,regulatoryprocedures,governmentpolicy,evidence-basedguidelinesand/orauthoritativeguidelinesorstatementsfromprofessionalcollegesorassociationswhichdescribeproceduresunderwhichPoCTmaybeperformedingeneralpracticeorthecommunity.
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These aims and objectives were achieved by this project.
Findings (OnlyfindingsapplicabletoAustraliahavebeenidentified;forinternationalfindingspleaserefertotheoriginalreport.) Use and Implementation of PoCT Devices PoCTisnotasingleunifiedentityanddifferentcircumstancesmayrequire
differentsolutions. Aprincipalconclusionarisingfromthequalitymanagementaspectofthe
AustralianGovernmentfundedmulti-centrePoint-of-Care Testing in General Practice Trial(http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pathology-poctt-index.htm)foundthetrialmodelprovidedaframeworkthatworkedwithinthecurrentregulatoryenvironment.ThisframeworkcouldformthebasisfortheimplementationofPoCTingeneralpracticemorebroadly.
Point-of-Caredrugtestingisgenerallydesignedtoscreenforthepresenceofdesignateddrugsorgroupsofdrugs.
Quality Assurance Inorderforequivalentclinicaldecisionstobemade,theaccuracyand
reliabilityoflaboratorytesting,includingPoCT,shouldnotbesitedependent. TheadvantagesofPoCTtestinglargelydependonproofofacceptable
analyticalperformance.Thisconceptdominatespolicystatementsfromgovernmentagenciesofmanyjurisdictions,articlespublishedinpeer-reviewedjournalsandstatementsmadebyinternationalprofessionalcommentatorsonPoCT.
Therearemany‘official’andprofessionallybasedstandardsandguidelineswhichdefinethemannerinwhichPoCTshouldbeimplemented,managedandtheperformancequalitycheckedandmaintained.Most,ifnotall,professionallybasedguidelinesfollowasimilartemplateandprovidesimilarinformationwhichincludesspecificreferencetoqualitycontrolandqualityassurance.
Regardlessoftheparticularassayormethod,PoCT,incommonwithalllaboratorytesting,requiresregularqualitycontrolandexternalqualityassessment(EQA)toassureacceptableperformance.ThereisalsoagrowingliteraturedescribingthepotentialandactualerrorsarisingfrompoorlycontrolledPoCTwhileinspectionandaccreditationprocesseshavebeenverysuccessfulinachievingthegoalofreducingPoCTerror.
Therequiredanalyticalperformanceofatest(fitnessforpurpose)isdeterminedbyitsintendedclinicaluseandnotbythelocationwheretestingoccurs.Theaccuracyandreliabilityoflaboratorytesting,includingPoCT,shouldbeequivalentirrespectiveofthetestingsiteforequivalentclinicaldecisionstobemade.
ThePoint-of-Care Testing in General Practice Trial providedconfirmationthatqualitymanagementpracticesarerequiredforPoCT.
ForPoCTtoprovidevalueinthegeneralpracticesetting,aneffectivequalitymanagementsystemisessential.Cliniciansneedreassurancethattheir
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decisionsarebasedonreliable,accurateandpreciseresultstoensurepatientsafetyisnotcompromised.
Actualclinicaltrialsorlarge-scalereviewstoassesstheeffectivenessofPoCTaremuchlessnumerousthanpublicationswhichdescribethepotentialrisksassociatedwithPoCTandissueswithspecificdevicesorwithspecifictests.
Cost Issues TheinnovationandfunctionalityofPoCTbringsmanychallengesforhealth
carefundingauthorities,particularlythevalueitmaybringtothepatientcareprocess.
PaymentformosttypesofPoCTisavailablethroughMedicareprovidedsuchtestingisundertakenbyanaccreditedpathologyservice(laboratory).
Withtheexceptionofspecialfundingarrangements(suchasQualityAssuranceforAboriginalandTorresStraitIslanderMedicalServices[QAAMS])orStateGovernmentsponsoredpublichospitalPoCTtesting,onlyaccreditedPoCTlaboratoriesmayreceiveGovernmentreimbursementor(Medicare)testingfees.
Whencostsofimplementingaqualitysystemareraised,therealquestiontoaskishowmuchispoorqualitygoingtocostorhowmuchisitcostingnow?Theprincipalissue,particularlywhendiscussinghealtheconomics,istheinfluenceof“costshifting”,intermsofpoorqualityofonesectorofthehealthsystemsaddscoststoanothersectorasincreasedresourcerequirements.PoorqualityinlaboratoryandPoCToftenresultsinincreaseddoctorvisits,additionalunnecessarytestprocedures,inappropriatelychangedmedicationoradditionalunnecessarymedicationand/orhospitalisation.Therealcostofnotidentifyingtestingproblems,orunnecessaryrepeattestingandpoorpatientoutcomes,isoftenhiddenuntilaqualitysystemhasbeenimplemented.
Follow on Initiatives and Projects
Itisanticipatedthatthisworkwillbepromotedinascientificjournal. PoCTTraining,Certification,SupportandSkillMaintenanceProgram
(AustralianPoCTPractitionersNetwork–APPN)(Current).
Areas for Future Consideration
InvestigatetheframeworkforPoCTinGeneralPracticerecommendedbythePoint-of-Care Testing in General Practice Trial (http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pathology-poctt-index.htm.)
InvestigateanddefineQAissuesforPoCT.
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PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current)
Description Thisprojectisseekingtoestablishatraining,competencyassessmentandongoingeducationinfrastructureforPoint-of-CareTesting(PoCT)deviceoperatorsknownastheAustralianPointofCarePractitionersNetwork(APPN)
Grant Recipient AustralasianAssociationofClinicalBiochemists(AACB)
Aim
toprovideaccesstoatrainingandsupportservicethatwillallowPoCTdevicestobeoperatedbyhealthpersonneltoadequateclinicalstandards.
This project is current and this aim is in the process of being achieved.
Outcomes
CoreeducationandassessmentmoduleshavebeenestablishedforcompetencyintheoperationandmaintenanceofPoCTdevicesinsettingsoutsidelaboratories(suchasgeneralpractices)whichcanbedeliveredbyRegisteredTrainingOrganisationsandusedunderrelevantaccreditationframeworksasabasisforcompetencyassessment.
TheDiabetesModuleshavebeenapprovedbytheRoyalAustralianCollegeofGeneralPractitioners(RACGP),theAustralianCollegeofRuralandRemoteMedicine(ACRRM)andtheRoyalCollegeofNursingAustralia(RCNA)ascountingpointsfortheircontinuingpersonaldevelopmentprograms.
TheINR(InternationalNormalisedRatio)AnticoagulationModulehasbeenapprovedbytheACRRM.
TheLipidsModuleiscompletewithmodulesforPoCTforcardiacmarkersandcardiopulmonaryresuscitation(CPR)currentlyindevelopment.
Guidelines,whereavailable,havebeenincludedintothecontentofthemodules.
InDecember2011almost800peoplewereregisteredasAPPNmembersandover620competencyassessmentshadbeenperformedwiththeproportionofcompetencytestspassedcontinuingtoincreaseasthematerialcontentincreased.
Establishment of a Molecular Genetics Quality Assurance Program (Current)
Description Thisprojectisseekingtoimproveexistingandnewqualityassurance(QA)modulesforexternalassessmentofmoleculargenetictests.
Grant Recipient RCPAQualityAssuranceProgramsPtyLtd(RCPAQAP)
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Aim
toimprovethequalityofgenetictestinginAustralianlaboratoriesbyestablishingastand-aloneprogramfortheexternalqualityassessmentofmoleculargeneticswithinthecurrentqualityassuranceprogramprovidedbyRCPAQualityAssuranceProgramsPtyLtd.
Objectives
toestablishanexpandedmethods-basedexternalqualityassessmentofmoleculargeneticprogramforincorporationintotheMolecularGeneticsQualityAssuranceProgram(MGQAP)whichwillbetrialedinthelatterpartof2009forintroductionasaformalRCPAQAPProgramin2010
tochangeadministrationoftheexistingHumanGeneticsSocietyofAustralasia(HGSA)ProgramintotheestablishedRCPAQAPwithjointadministrationbytheRCPAQAPandHGSA
todevelopnewtechnicalmodulesfortheexternalqualityassessmentofmoleculargenetics
todevelopproceduresanddocumentationtoallowInternationalLaboratoryAccreditationCooperationG13:2000standardaccreditation
toestablishtheproceduresanddocumentationtoallowMGQAPtooperateasaself-fundedstand-aloneprogramafterthecompletionoftheproject.
This project is current and the aim and objectives are in the process of being achieved.
Outcomes
NineMGQAPmoduleshavebeendeveloped. Alaboratoryhasbeenestablishedtoenableaccuratepreparationofgenomic
DNAsamplesforqualityassuranceandsampleexchangemodules,togetherwithaDNAbankwhichiscurrentlyexpandingwithadditionalsamples.
WorkhascommencedinpreparationfortheaccreditationoftheMGQAPincludingholdingdiscussionswiththeNationalAssociationofTestingAuthorities(NATA)foraplannedassessmentinJune2012.
Asampleexchangeregistryhasbeenestablishedforsmallertestnumberswherenoformalqualityassuranceprogram(QAP)currentlyexiststoassistlaboratoriesincomparingtestresults.
Abasicinformativewebsiteisplannedforearly2012withamorecomprehensivesiteplannedforamidyearrelease.
MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current)
Description Thisprojectisdevelopingadatabase(theMAWSONDatabase)toholdgeneticdatacollectedsemi-automaticallyfromparticipatingAustraliangeneticlaboratoriesforuseasareferencetooltoenablebest-practicereportingofgenetictesting.Thedatabasecanbehandedovertoasuitableorganisationtoallowittooperateasaself-fundedstand-aloneprogramafterthecompletionof
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theprojectwiththeintentofmaximisingparticipation.DatawillalsobeuploadedfromtheMAWSONDatabasetotheInternationalHumanVariomeProject(HVP).Moreinformationcanbefoundat:http://www.mawsonproject.com.
Grant Recipient UniversityofSouthAustralia
Aim
todevelopadatabase(theMAWSONDatabase)thatwillretaingeneticdatacollectedsemi-automaticallyfromparticipatinglaboratories.Thesedatawillbeaccessibletoagroupofcollaboratingmedicalgeneticlaboratoriesintheformofa“virtuallabmeeting”toenablethedevelopmentofbestpracticereportingofgenetictesting.Theprogramwillinitiallyestablishadatabaserepositorywithfamilialbreastcancermutations(BRCA1andBRCA2genes)fromgeneticlaboratoriesthroughoutAustralia.
This project is current and this aim is in the process of being achieved.
Outcomes
TheprojecthassuccessfullytestedtheprototypeatFlindersMedicalCentre,SA,withpublicationofthesourcecodeforlaboratoryaccess(MawsonClient).
Undertakingfurthertestingoftheprototypeatotherlaboratorieshasdelayedtheproject.TheFamilialCancerServiceatWestmeadHospitalNSW,andtheMolecularGeneticsLaboratoryatPathologyQueensland-CentralLaboratoryhasagreedtotesttheprototype
InitialdiscussionshavebeenundertakenwiththeRCPAQualityAssuranceProgramsPtyLtd(RCPAQAP)regardingtheongoingmaintenanceandpossiblecommercialisationofthedatabasewhentheprojecthasbeencompleted
AformalagreementhasbeennegotiatedwiththeHVPtocollecteligibledatainSAandconveyittotheHVPdatabasetoallowdatacomparison.
Areas for Future Consideration
FurtherpossibleworkbytheGeneticsWorkingPartysetupunderthePathologyFundingAgreement.
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eHealth Capability TheQualityUseofPathologyProgram(QUPP)hasenabledvariouseHealthcapabilitiesthrough12projects(Table5).TheriseoftheInternetandtherapidchangesinthescopeandcapacityofInformationTechnology(IT)providedextrachallengestomanyoftheseprojectsasevidencedbytheexpansiveKeyProjectLearningsforanumberoftheseinitiatives.TheselearningsalsoprovidedavaluablesourceofinformationandinsightaboutconductingfutureprojectswithintheeHealthparadigm.Theadventoftheabilitytoorderpathologytestselectronicallyalsorequiredanalysistoinvestigateanyimpactsontheorderingpatternsofpathology.Receivingresultselectronicallywasalsoinvestigated,especiallyfornarrativereports.KeyissuestoemergeforeHealthcapabilityincluded: softwareinstallationissuesdelayingprojecttimelines thevariedlevelsofITproficiencyandknowledgeamongtreating
practitioners findingabalancebetweenITsolutionsandtreatingpractitioner’stimeand
motivationtoimplementthesesolutions differentpathologyterminologyonpathologyreports.ThefollowingareasforfutureconsiderationineHealthCapabilitywerebasedaroundtheseissues.Theyinclude: Identifytheevidenceofbenefitsandincentivesfortheelectronic
transmissionofpathologyrequests. Optionalautomateddecisionsupport,andstandardtermsforrequestsand
results. Standardsforalertsandabnormalresults(addressedinApplicationof
PathologyInformaticstoReportingofCritical/AbnormalResultsforImprovedRequester/ProviderCommunicationandImprovedPatientCare onpage 82) andstandardsthatwouldallowforclinicaldataanalysis.
GeneralPractitioners(GPs)wouldlikemorepatient-specificadviceandarehappyforthistobeonpathologyreports.Forrequestingitmustbeatthetimeofmakingtherequest.
MarketingtheRoyalCollegeofPathologistsofAustralasia(RCPA)ManualforPathologyTestingtoGPs.
AddressquestionsfromAStudyoftheImpactoftheUseofGeneralPracticeComputerSystemsontheOrderingofPathologyonpage78whichinclude:
o Whataretherelativeranksoftheperceivedreasonsforobservedincreasesintestsorderedperepisode?
o Doescomputerpromptinghelporhindergoodpracticeinpathologyordering?
o WhatistherelativevalueofpathologyinGPpractice?o Howmuchtestingisorderedandnotdone?o Howmuchtestingisperceivedtoberepeatedunnecessarily?
BedsideaccesstoITformultiplepurposes(laboratory,radiology,dischargesummariesetc.).
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Collectalargercorporafordiseasecategoriesthataremorecomplexintheirpathologytestinganddescriptionsforsynopticreportsfromnarrativepathologyreports.
[alt=“ThefollowingtableliststhetwelveprojectnamesandgrantrecipientsundertheeHealthCapabilitytheme”] Project Name Grant Recipient/s 1 PathologyInformaticsWorkingParty(2003) RoyalCollegeof
PathologistsofAustralasia(RCPA)
2 DevelopmentofonOn-lineMaintenanceSystemfortheAustralianPathologyRequestandResultCodeSets(2003)
UniversityofSydney
3 PathologyandGeneralPracticeSoftwareIntegrationProject(PaGSIP)(2003)
UniversityofBallaratandQueenslandMedicalLaboratory
4 ChainofInformationCustodyforthePathologyRequest-Test-ReportCycleinAustralia(GuidelinesforPathologyRequestersandPathologyProviders)(2004)
RCPA
5 SupportingHL7forHealthInformaticsStandards(2004) HL7AustralasiaUserGroupIncorporated
6 AStudyoftheImpactoftheUseofGeneralPracticeComputerSystemsontheOrderingofPathology(2004)
MichaelLegg&Assoc;IRISResearch;UniversityofWollongong;DrIanCheong
7 ApplicationofPathologyInformaticstoReportingofCritical/AbnormalResultsforImprovedRequester/ProviderCommunicationandImprovedPatientCare(2004)
MaterMisericordiaeHealthServicesBrisbaneLimited
8 PadlokOn-linePathologyOrderingSystem(2005) FremantleHospital9 InformationExtractionfromNarrativePathologyReports
onMelanoma(2008)UniversityofSydney
10 AutomaticCompilationofSynopticReportsfromNarrativePathologyReports(Stage2)(2010Submittedwiththetitle:ThePathologyReporter)
UniversityofSydney
11 AutomaticPopulationofSynopticReportsfromNarrativePathologyReports(Stage3)(Current)
UniversityofSydney
12 StandardisationofPathologyTerminologyandUnits(Current)
RCPA
Table 5: Projects summarised for eHealth Capability
Pathology Informatics Working Party (2003)
Description ThePathologyInformaticsWorkingParty(PIWP)wasestablishedin2003todevelopapolicytoassistintheimplementationofhealthinformaticsforpathology.TheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)fundeditsfirstyearofoperation,andtheRoyalCollegeofPathologistsofAustralasia(RCPA)fundeditssecondyearofoperation.TheInformationandCommunicationsDivisionwithinDoHAsubsequentlytookoveralle-Healthactivities.
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Grant Recipient RCPA
Aims and Objectives
todevelopanRCPA-endorsedpolicyforinformatics topublishusefulwebsitesforpathologistsinseveraleditionsofPathology
Today todevelopPathologyInformaticseducationpackagesforTraineesand
FellowstoassistinthedisseminationanduptakeofHealthOnlineinitiatives topromoteHealthInformaticsatPathologyUpdateconferences todevelopadiscussionpaperontheroleofinformaticsandthepathologist
inpatientcare torepresenttheRCPAonvariouscommittees toparticipateintheactivitiesofHealthConnect throughvariousprojects
beingcarriedoutbyFederalandStateHealthDepartments.These objectives were either achieved or in the final stage of completion when the report was tabled. The PIWP also submitted a Laboratory Decision Support System proposal which was unsuccessful. The RCPA subsequently developed an electronic updated version of the Manual of the Use and Interpretation of Pathology Tests (see Follow On Initiatives and Projects below).
Outcomes
PIWPwaspromotedinvariousways. Adiscussionpaperontheroleofinformaticsandthepathologistinpatient
carewasindevelopmentandduetobecompletedbythenewworkingpartywhenitwasconstituted.
Informaticstrainingwastobeintegratedintothetrainees’specialtycurriculumalthoughtopicsofinteresttoalltraineeswillbepresentedtothegroup.
TheChainofInformationCustodyforthePathologyRequest-Test-ReportCycleinAustralia(GuidelinesforPathologyRequestersandPathologyProviders)reportwasnearingcompletionbytheRCPA.ThisreportwasfundedbytheQualityUseofPathologyProgram(QUPP)butnotendorsedbytheQualityUseofPathologyCommittee(QUPC)astheynoteditrequiredfurtherrefinement.
Findings
InformaticsandelectronichealthrecordsareanimportantandintegralpartofthefutureoftheAustralianhealthcaresystem.
Newapproachestotechnologywillbemorereadilyacceptedbyaprofessioniftheyareintroducedasanadjuncttoexistingprofessionalpracticeratherthanasanewandunfamiliardisciplinewithitsownphilosophyandlanguage.
Incorporatinganappropriatelevelofinformaticsskillandexpertiseintothepracticeofpathologywillbefacilitatedifthecontributionofinformaticsiscouchedintermsofexistingpathologypractice.
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Follow on Initiatives and Projects
RevisionofManualofUseandInterpretationofPathologyTestsonpage17
toupdateitscontentandmakeitavailableviatheRCPAwebsiteinaformatfacilitatingsearching,downloadingandincorporationintoothersoftware
TheChainofInformationCustodyforthePathologyRequest-Test-ReportCycleinAustralia(GuidelinesforPathologyRequestersandPathologyProviders)reportonpage76.
Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003)
Description Thisprojectsoughttodevelopanon-linemaintenancesystemforpathologyrequestandresultcodesets.ItfollowedworkbyStandardsAustraliatoprovideacommonsetofrequestcodesforusebysoftwaremanufacturersinbuildingsystemsfortheelectronicorderingofpathology.
Grant Recipient UniversityofSydney
Aims and Objectives
toreviewthecodesetproducedbyStandardsAustralia toupdatereferencestothePathologyServicesTable(PST)toallowthecode
settobeincorporatedintotheMedicareBenefitsSchedule(MBS) tobuildanonlinefacilitytocaterformultiplepurposes tousethesameplatformforothercodesets toundertakeadditionalworktoaccommodatepathologyresultcodes.Secondaryobjectiveswere: toprovideareferenceterminologyforthecodingofpathologyrequestsfor
research toprovideamaintainedlistof“abbreviations”tobeusedonpathology
accountstomeettherequirementoftheAustralianHealthInsuranceActintheidentificationofthebilledprocedure.
These aims and objectives were achieved by this project.
Outcomes
Phase1-ConductadesktopaudittocheckeachcodeentryinthetablesetoutintheStandardsAustraliaReportagainstitsreferenceinthePathologyServicesTable.
Phase2–Developanon-linemaintenancesystemforthePathologyRequestCodeset.
Phase3–Conductadditionalworktotheon-linemaintenancesystem. Phase4-CommencehostingtheOn-lineMaintenanceSystems(developedin
phasestwoandthreeoftheproject)bytheUniversityofWollongong.
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TheOn-lineMaintenanceSystemfortheReportCodeSetwasdemonstratedandhandedovertoStandardsAustraliaIT-14-6-5fortheiruseincommencingwiththemaintenanceofthefortheirusetobeginthemaintenanceofAUSPRPtheAustralianPathologyReportCodeseton7November2003.
Recommendations 1. Encourageimplementationofthelistsbypathologypracticesandthemedical
softwareindustry.2. EnsuretheuseofthecodesetsinGovernmentprojectssuchas
HealthConnect.3. IncorporateRequestCodeSetintotheMBS.
Key Project Learning
Therewasmoredifficultyingettingadequatetestcodeliststhanbuildingthewebsite.
Follow on Initiatives and Projects
IntegrationwithNationalE-HealthTransitionAuthority(NeHTA)workprogram.
Version1.04oftheRequestCodesetwasincorporatedintotheupdateoftheAS4700.2ImplementationofHealthLevelSeven(HL7),Version2.3.1Part2:Pathologyordersandresults.
Pathology and General Practice Software Integration Project (PaGSIP) (2003)
Description Thisprojectsoughttoimplementtheelectronictransferofpathologyordersfromgeneralpractitioners(GPs),andpathologyresultsbacktoGPs,usingHealthLevelSeven(HL7)messagingstandardsandPublicKeyInfrastructure(PKI)security.TheCommonwealthwantedtheseprojectsbasedonthe“AustralianHandbookonPathologyMessagingusingHL7Version2.3.1”aspublishedbyStandardsAustralia.
Grant Recipients UniversityofBallarat;QueenslandMedicalLaboratory
Aims and Objectives
demonstratetimesaving,effectiveandconsistentorderingofpathologyorders
demonstratetimesaving,effectiveandconsistenttransferofpathologyresults
demonstrateaninfrastructureandGPdesktopprocessesthatenablepathologydatatobebetterhandledbytheGP
demonstrateimprovedaccuracyofdatacapture,facilitateimprovedpathologyworkflowandincreaseaccuracyofmatchingresultstoorders.
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These aims and objectives were only partially achieved due to delays in getting the messaging system installed and working satisfactorily. This resulted in only one GP practice in Ballarat effectively sending and receiving pathology HL7 messages.
Findings
Codesetswouldplayausefulpartinfurtherpathologyorders/reportsprojects.
Theeaseofuseoftheprocessfororderingpathologytests,andtheabilitytotrackorderingofpathologytests,wereadvantagesofthismessagingsystem.
DelaysintheinstallationprocesscausedsomeunrestwithGPs,however,oncethetrialcommencedandthebenefitsofthesystemweredemonstratedtherewasacceptanceofthesystem.
Recommendations 1. TheuseofHL7messagingcapabilitiesHL72.3.1shouldbeencouragedwithin
generalpracticepathologyinformationsystemproviderstofacilitatefurthertrials.
2. Incorporatethespecifiedchangestothe‘PathologyHandbook’asidentifiedinthisproject.
3. ConductaworkshopforallpathologyinformationsystemsprovidersandpracticemanagementproviderstoencouragethemtodevelopHL7messagecapabilitiestoHL72.3.1asaminimum.
4. Conductasecondtrialwithalaboratorytoreceiveelectronicpathologyrequestsandsendelectronicpathologyresults.Runthetrialoveranextendedperiodoftimetodemonstratetheeffectivenessofelectronicmessagingonpracticeandlaboratoryworkflowandimprovedpatientcare.
5. UsepathologyordercodesintheACTHealthInformationNetworkPilottostreamlineorderingpathologytests.
6. ImplementandtrialtheuseofatomiseddatatounderpinelectronicdecisionsupportinGPsoftware.
7. Conductcostingofbenefitsofelectronicrequestprocessingtopathologypractices.
Key Project Learnings
ProceduralissuesweremanyandvariedandrangedfromthosespecificallyrelatedtotheGPpracticemanagementsoftware,thelaboratoryinformationsystem,PKIimplementationsandArgussoftware.
TheprocessforobtainingHeSA/PKIlocationcertificatesshouldbestreamlined.
Athoroughriskanalysistoexaminethehardwareandsoftwareinfrastructureofthepractice,andacompletereviewofcurrentworkpractices,shouldhavebeenimplementedatthecommencementoftheproject.
AtleastoneGPshouldhaveparticipatedinsteeringcommitteemeetings. ThereshouldhavebeencloserinvolvementofDivisioninformation
technology(IT)staffwithCollaborativeCentreforeHealth(CCeH)ITstaffthroughthedevelopmentandinstallationphasesoftheproject.
ThereshouldhavebeenacloserliaisonwithGPpracticestaff,DivisionITstaffandCCeHITstafftodeterminethemostefficientmethodofgettingsoftwareinstalled,testedandworkingsatisfactorily.
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WorkingwithgeneralpracticeinfutureprojectsrequiresconsiderablymoreinteractionwithGPsandtheirpracticestaff.Thisinvolvescompleteinvolvementofpracticestaffintheprojectprocesses,includingparticipationatsteeringcommitteelevel,thoroughpre-trialanalysisofallworkflows,hardwareandsoftwareconfigurationsandsoftwareusage.
AccesstoGPpracticesisproblematicduetotheirveryspecifictimesoflowactivitywhichwereduringlunchtimesandafterhours.However,afterhoursaccesswasdifficulttonegotiateduetosecurityandconfidentialityissuesaroundpatientdata.Thisleftlunchtimesasthemainaccessopportunitywhichresultedinalongerthananticipatedinstallationprocess.
Pathologylaboratoriesreceivehundredsofspecimensdailyforprocessing,andanyinstallationsmustaimforminimaloperationaldelays.
Ensurethoroughandcompletetestingiscarriedoutinalaboratoryenvironmentpriortoinstallationattestsites.Oncetestinghasbeencompleted,signoffbytheappropriatestakeholdersisrequired.
Implementationofsoftwareinfuturetrialsneedsrigoroustestingsothatonceinstalleditisoperatingcorrectlyandrisksofsoftwarefailureareminimised.Thisistoensureminimalimpactonpractice/laboratoryworkflowsandmaximumopportunitytoachievestatedprojectoutcomes.
Theoriginalprojecttimeframeofsixmonthswastooshorttoachievetherequiredoutcomes.Theprocessofgettingallpartiestoproducethenecessarycomponentsoftheprojectwasmorecomplicatedandlengthythanoriginallyestimated.A12monthtimeframewouldhavegivenadequatetimetoengageallstakeholdersandhaveallsoftwareworkingcorrectly.Itwouldhavealsogivenalongertimetorunthetrialandhencemoreweighttotheevaluationprocess.
Thetrialsizeandperioddidnotyieldlargenumbersofpathologyresultsandrequestsbeingtransmitted.Thismeantthestatisticalbreakdowndidnotyieldsufficientnumberstobeuseful.
Follow on Initiatives and Projects
IntegrationofrelevantelementsintoNationalPathologyAccreditationAdvisoryCouncil(NPAAC)requirementsandguidelines.
Areas for Future Consideration
Identifytheevidenceofbenefitsandincentivesfortheelectronictransmissionofpathologyrequests.
Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)
Description Thisprojectdevelopedguidelinesforusebymedicalpractitionerswhenrequestingpathologytests,andforusebypathologyprovidersoperatinginbothpublicandprivatepractice.Theyarenotprescriptive.
Grant Recipient RoyalCollegeofPathologistsofAustralasia(RCPA)
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Aims TheGuidelinesaimto: identifywhoisresponsibleforensuringthecorrectproceduresfor
informationintegrityandtransferandrelatedprocessesarefollowedateachstageoftheRequest-Test-ReportCycle
encouragetheimplementationofsoundmanagementsystemsthatmonitortheinformationprocessescomprisingtheRequest-Test-ReportCycletoensurethehigheststandardsofpatientcarearemaintainedatalltimes
ensurepatientconsentisobtainedandprivacyisrespected createasystemthatprovidesforqualityandsafetyofhealthcareand
contributestoimprovedpatientoutcomes.These aims were achieved by this project.
Outcome
ThisreportwascompletedwithfundingbytheQualityUseofPathologyProgram(QUPP),butwasnotendorsedbytheQualityUseofPathologyCommittee(QUPC),astheynoteditrequiredfurtherrefinement.
Follow on Initiatives and Projects
IntegrationofrelevantelementsintorelevantNationalPathologyAccreditationAdvisoryCouncil(NPAAC)requirementsandguidelines.
Supporting HL7 for Health Informatics Standards (2004)
Description HealthLevelSeven(HL7)AustraliarequestedandwasgrantedfundingtoorganisetheselectionandattendanceofonedelegatetoparticipateintheOrdersandObservationsTechnicalCommitteeofHL7Inc.
Grant Recipient HL7AustralasiaUserGroupIncorporated
Aims and Objectives
toensureapersonofappropriateexpertiseattendstheinternationalmeetingsofHL7Inc.
toconveytheworkbeingdoneinAustraliaandrepresentAustralianinterests
tofacilitatethedevelopmentofdraftstandardsinHL7messagingforPathology
topresentnewrequirementsarisingfromthedevelopmentoftheStandardsAustraliaImplementationGuide(seefindingsandrecommendationsbelow).
These aims and objectives were achieved by this project.
Outcomes
MrRichardHardingwaschosenasthedelegatetoattendinternationalmeetingsofHL7Incalthoughhisqualificationswerenotidentifiedinthereport.
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Australianpathologyorclinicalpractices,particularlywhentheyvariedfromUSandBritishpractices,weredescribedbyMrHardingduringthediscussionopportunitiesatmeetings.
MrHardingparticipatedinarangeofmeetings,workinggroupsandteleconferences.
Finding
ItwasreportedthattheV3PathologySpecificationwouldhaveanimpactontheAustralianstandards.SomelaboratoriesandhospitalswerealreadyflaggingtheirinterestinmovingtoV3fortheirpathologymessages.
Follow on Initiatives and Projects
PossiblefollowupactivitiesthroughtheeHealthandpathologyfocusinthePathologyFundingAgreement.
A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004)
Description Therehadbeenanoverallincreaseatthenationallevelintheorderingofpathologytestsandintheratioofpathologytestsordered,betweenJanuary1999andDecember2001.Thisstudysoughttodeterminetheextenttowhichtheobservedincreaseinthecontentofanepisodecouldbeexplainedbytheincreaseduseofcomputersystemsfortheproductionofpathologyrequests.
Grant Recipients MichaelLegg&Associates;IRISResearch;UniversityofWollongong;DrIanCheong.
Aim
todeterminetheextenttowhichtheobservedincreaseinthecontentofanepisodecouldbeexplainedbytheincreaseduseofcomputersystemsfortheproductionofpathologyrequests.
This aim was achieved by this project.
Outcomes Phase 1 Aqualitativeassessmentbasedonfocusgroupstodeterminetheperception
ofachangeinbehaviourandattitudesaboutpathologyordering.ThesewereheldinBrisbane,SydneyandMelbournein2001withparticipantsrecruitedusinglocalnetworksofgeneralpractitioners(GPs)interestedininformatics,orthroughmasscommunicationbyDivisionsofGeneralPractice.Participantsreceivedafeeof$100fortheircontribution.
Phase 2 Aquantitativesurveyofpreference,attitudeandstatedbehavioursofGPs
aroundpathologyordering.Incentiveswereprovidedtoparticipateandahighresponserateof41%(613)wasachieved.Ofthese,91%(557)
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consentedtothereleaseofHealthInsuranceCommission(HIC)dataforthetimeseriesanalysis(Phase3)whichrepresentedanoverallresponserateof37%.
Phase 3 Aretrospectivetime-seriesanalysisofMedicarestatisticsfortwocohorts–
thoseknowntobeusingcomputerproducedpathologyrequestsandthoseusinghandwrittenrequests.Pathologyrequestingdatarelevantto532GPs,whogaveconsentforthereleaseoftheirrequestingdataaspartofthePhase2survey,wasanalysedfortheperiodJanuary1999toDecember2001.
Phase 4 AprospectivestudydesignaroundGPcomputersystemsandpathology
requestingrecommendedinthereportisablindedcrossoverstudytoinvestigatehowGPcomputersystemsmightinfluencepathologyrequestingtowardbestpractice.
Findings Phase 1 Thestrongestconcernsinfluencingpathologyordering,apartfromclinical
indications,weremedico-legalconsequencesandpatientdemand. Pathologyreportingandrequestingrankedhighlyamongusefulfunctions. GPscommonlylearnedtouseacomputerfrom“trailblazing”GPmentors
whotendedtocarryasignificantburdenfortheirpractices. GPslearnwhattheyneedtogivethemthebest“bangforthebuck”. Despitethewidespreadusageofelectronicpathologyreportingand
requesting,manyGPswerenotyetpreparedtoforgopaper. Pathologytestorderingwasinfluencedbymanyfactors. Optionalautomateddecisionsupportandstandardtermsforrequestsand
resultsareseenasdesirable.Phase 2 66%ofGPsutilisesomeformofcomputerisedorderingtorequestpathology,
with55%usingMedicalDirector(83%ofthesub-sample).Manyotherstatisticswerenotedinthereport,however,thetwohighlightedwere:
o 75%ofrespondentsreportedtheyorderedneithermorenorlesswhenusingacomputerisedorderingsystem,17%indicatedtheyorderedmoreandonly4%indicatedtheyorderedless.
o 70%ofGPsreportedimprovedpatientmanagementarisingfromtheuseofcomputerisedpathologyrequesting;52%reportedthelevelofthistobesignificant.
Asidefrommanagingpatientcare,respondentsrankedthefollowingfactorsfromhighesttolowestaccordingtotheperceivedimpactontheirrequestingbehaviour:1. medico-legalconsiderations2. patientdemand3. healthbureaucracyandadministrativerequirements4. promotionoradvicefrompathologypractices5. businessandmarketingconsiderations6. easeofordering.
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Therearedifferencesinreportedbehaviourbetweenpracticetypes:solepractitionersreportedbeingmoreinfluencedbypathologypracticesandhealthbureaucracy,whilethosefromlargerpracticesreportedestablishingproficiencyearlier.
Phase 3 Therewaslittleevidencethatthecomputerisationofdoctor’spathology
orderingsystemsledtoanincreaseinthenumbersofpathologytestsorderedperpatientincident.
Therewasatendencyforsomedoctorstochangetheirpathologyorderinghabitsduringtheobservationperiod.Thischangewasnotuniformindirectionanddoesnotexplaintheoverallincreaseinorderingnoted.
ChangesinorderingrateswereinconsistentbetweenthevariousStatesandTerritories.
Thereisnostatisticallysignificantdifferencenationallyintherateofchangeinpathologytestsperepisodebetweenthosedoctorswhodidnotuseacomputerisedsystem,andthosewhocomputerisedduringthestudyperiod.
ThefindingsfromtheanalysisofMedicareutilisationdatadidnotsupporttheviewsexpressedbyGPsinphasesoneandtwo.
Itispossibletheobservedincreaseinservicesperepisodewerecausedbysomechangeinthereportingsystem,suchashowthedataonservicesassociatedwithanepisodeisconstructed,ortherehadbeenachangeinmedicalpracticeoverthisperiod,orachangetothepopulationbeingtestedsuchasitsrelativeageing.
Phase 4 Ablindedcrossoverstudydesignwasprovidedinthereporttoinvestigate
howGPcomputersystemsmightinfluencepathologyrequestingtowardbestpractice.Thestudydesigngivestheopportunitytofurtherinvestigatepathologyutilisationdataandexpandontheobservedtrendofincreasedservicesperpathologyepisode.
General GPsfindusingtheircomputertorequestpathologyeasierthanwriting,and
believeitimprovespatientcare. PaperlesselectronicrequestsdidnotseemtobeahighpriorityforGPSsince
theyfeltpatientsstillrequiredapieceofpapertotakeaway. Whilethefactorsinfluencingpathologyordering(apartfromclinicalfactors)
weremanyandvaried,therewasgeneralagreementthatthestrongestwereconcernformedico-legalconsequencesandpatientdemand.
Softwareinterfacedesignmustallowforquick,easyandaccurateinformationentry.Keyboardentryispreferredbythosewhocantypebecauseinformationcanbeenteredwhileinterviewingthepatient.
Implementationofsystemsneedstobephasedandledbyalocalchampionandmentor.
GPsfindusingtheircomputertorequestpathologyeasierthanwriting,andbelieveitimprovespatientcare.
GPsgenerallydon’tunderstandtheimportanceofclinicalnotesforpathologypractices,andsomebelievetheyarenotusedbythepathologypractices.
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Thegreatestuptakeofcomputerisedmanagementsystemsoccursatthebeginningofthenewcalendaryear,andattheendofthefinancialyear.
Thegenerationoftestgroupsandpanelsrequiresfamiliarityandhigherproficiencywithpracticemanagementsoftwareandisthereforelikelytoincreaseovertime.
Solepractitionersindicatedthatpromotionoradvicefrompathologypracticeshasahighimpactonpathologyrequests.
GPswantmoreanalysisoftheirdataandarefrustratedwiththeircurrentsystem’scapacitytodothis.
GPswanttheirsystemtopromptactionswhereappropriate.
Recommendation 1. Theblindedcross-overstudydesignprovidedtoinvestigatehowGP
computersystemsmightinfluencepathologyrequestingtowardsbestpracticegivestheopportunitytofurtherinvestigatepathologyutilisationdataandtoshedmorelightontheobservedtrendofincreasedservicesperpathologyepisode.
Key Project Learning
Recruitmentinthefirstphaseofthestudywasdifficult.SignificantsupportfromtheDivisionsofGPswasrequired,andperhapsdirectlyfromthestudyorganisers,toobtainadequatesurveynumbers.
Areas for Future Consideration
Optionalautomateddecisionsupport,andstandardtermsforrequestsandresults,wereseenasdesirablebyGPs.
Standardsforalertsandabnormalresults(addressedinApplicationofPathologyInformaticstoReportingofCritical/AbnormalResultsforImprovedRequester/ProviderCommunicationandImprovedPatientCare onpage 82) andstandardsthatwouldallowforclinicaldataanalysis,werealsoseenasdesirablebyGPs.
GPswouldlikemorepatient-specificadviceandarehappyforthistobeonpathologyreports.Forrequestingitmustbeatthetimeofmakingtherequest.
MarketingtheRoyalCollegeofPathologistsofAustralasia(RCPA)ManualforPathologyTestingtoGPssincemostindicatedtheydidnotuseit,orknowofitsexistence.
Questionstobeaddressedfromthisstudyinclude:o Whataretherelativeranksoftheperceivedreasonsforobserved
increaseintestsorderedperepisode?o Doescomputerpromptinghelporhindergoodpracticeinpathology
ordering?o WhatistherelativevalueofpathologyinGPpractice?o Howmuchtestingisorderedandnotdone?o Howmuchtestingisperceivedtoberepeatedunnecessarily?
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Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004)
Description Thisprojectsoughttoconsiderappropriate,effectiveandtimelyreportingofcritical/abnormalpathologyresultstoproviders.Thisinvolvedcommunicationtotherequesterordesignatedphysician,andwasvitalprimarilyforoptimumpatientcareandfortheimportantissueofavoidingcostlylitigation.ThebasisoftheapproachwastousethefunctionsoftheLaboratoryInformationManagementSystem(LIMS)toincorporateasmuchofthefunctionalityrequiredaspossible.
Grant Recipient MaterMisericordiaeHealthServicesBrisbaneLimited
Aims and Objectives
todeveloptheprocessinitiallystartedinclinicalchemistry(MaterPathologyupdatedtheirpolicyonreportingcritical/abnormalresults12monthsbeforethisprojectstarted)tobemoresophisticatedandreducetheriskof“automatic”acceptanceofthenotificationofanabnormal/criticalresult
tointroducethenewprocessintohaematologyforfullbloodcountstoinitiallydevelopandmonitor
tointroducethenewprocessintoclinicalchemistryforthegeneralchemistriesandtherapeuticdrugsoncegeneralacceptancehasbeenobtainedinhaematology
todevelopcriticalprocessforcoagulationstudiesinhaematology tointroducetheuseof“phonecode”inhaematologyandmonitor tointroduce“phonecode”useintoclinicalchemistryifsuccessfulin
Haematology toconsiderintroducingintootherdivisionsastimepermits toreducethenumberofcritical/abnormalresultsbeingmisseddueto
numbersaturationofthescientists.Itwouldalsohelpensurecontinuitywhenstaffchangesoccurandarequestingdoctorordelegatehadnotbeenabletobecontacted(ascanoccurduringmealbreaksorshiftchanges).
These aims and objectives were achieved by this project.
Outcomes
Thecritical/abnormalresultsprocesswasduetobecommencedinbloodbankandimmunologyatthetimeofthereport.
TheprocessdidnotproceedinCordBloodBankbecauseofalackofinputintothesystem,butitwasflaggedtohappenwhentheinformationwasavailableandtherewastimetoimplementit.
Verygoodaudittrailswererecordedon-linestatingwhohadbeencontacted,whentheywerecontactedandhowoften.
Clinicalstaffpositivelynotedtheincreasedtelephonecallsduetothecriticalresultflaggingprocess.
Therateofsuccessofcontactingaresponsiblepersontodelivercritical/abnormalresultsincreasedfrom94%to97%.
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Thesystemimprovedtheworkpracticesofstaffastheydevelopedgreaterconfidenceintheflaggingsystem.
Finding
Theuseofthephonecodeinmicrobiologydidnotproduceasignificantbenefit.ThiswasduetoMicrobiologistsrecordingtheirnotesina“silent”fieldintheactualreportwhichisnotfinallyauthoriseduntilalltelephonemessagesandotheroperationshavebeencompleted.Thetelephonenotificationsystemremainedtherecommendedprocessforadhocresultreporting.
Recommendations 1. Flagssetinreportsmaybeusedinthefuturewiththelaboratory’sClinical
InformationSystemasameansofhighlightingthecriticalresultsaspartofaresultsmanagementprocessintheclinicalareas.
2. Theprojectwouldcontinueinthelaboratoryintheforeseeablefutureastherulesandassociatedprocessesarerefinedfurther.
Key Project Learnings
Thisprojectwastime-consumingbutworthwhile. Astheprojectgainedmomentum,andhardwaresystemschangedforthe
better,itbecamemoreacceptable. Determiningthepercentageofcritical/abnormalresultsreportedtothe
requesterwasnotpossibletoachieveasaretrospectivestudy. Itwasnotpossibletomeasuretheimpactonpatientcareinaquantitative
manner.
Padlok On-line Pathology Ordering System (2005)
Description Thisprojectsoughttoimprovelaboratoryrequestformdocumentation.
Grant Recipient FremantleHospital
Aims and Objectives
tomaximiseuseoftheon-linepathologyrequestsystembymedicalstaff todemonstratethatuseoftheon-linesystemreducestestrequesterrors toobtainfeedbackfromusersforfurtherdevelopmentoftheapplication totrialandevaluatevarious‘addon’decisionsupportfeaturessuchas
embeddedguidelines/warnings toinvestigateusefulwaysofmonitoringtestorderingpatternstoenable
feedbacktoclinicians todeterminetheadequacyofaccesstonetworkedpersonalcomputers(PCs)
inpatientareasandtheinfluencethishasonuseofthepathologyrequestsystem
These aims and objectives were achieved by this project.
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Outcomes
Theprojectachieveda50%rateofuseatthecompletionofthetrial. ThePadlokpost-implementationusersurveywasconductedinJune2004,
andanumberoffeaturesincorporatedintotheapplicationasaresult. Inthefirstninemonthsofoperationtheprojectteamconcentrateditsefforts
ontwomajordecisionsupportfeaturesintheareasof:o inappropriatetestrequestso duplicate/additionalforms.
Generalphysicianswereprovidedwithaconfidentialthree-monthauditontheaveragenumberoftestsandthede-identifiedratesforotherphysicians.Thisauditwastobeconductedmonthlyforanumberofmonthstodetermineifthisfeedbackhadaneffectonrequestingpatterns.Test-costsweresubsequentlyprovidedaswell.
Padlok-onlyworkstationswereinstalledinselectedclinicalareasandindoctors’commonrooms.
Findings Advantages ThemainadvantageofPadlokisitsresponsivenesstotherequirementsof
usersastheybecomeapparent. ThestudyfoundthatifalldoctorsusedPadlokthecompletionrateofrequest
formswouldbecloseto100%.
Use TheuseofPadloktendedtoperiodicallydropforabouttwoweekswhen
juniormedicalstaffrotationsoccurred,androseagainwhennewstaffweretrainedtousePadlok.
Testingwasnotreduced,althoughdataindicatedthatinappropriatetestinghadbeenreduced.
Padlokisthepreferredmethodinclinicalsettingswherethereisaregularphlebotomyservice,whileitwasquickerandeasiertouseahand-writtenrequestforminotherclinicalsettings.
PadlokwasusedextensivelyintheIntensiveCareUnitwheremanytestrequestswereroutineandrepetitive.
Padlokofferedsignificanttimesavingbenefitsforclinicianswhodidnothavetosourcepatientinformationthemselves,andforthelaboratoryintermsofrapidlyprocessingrequests.Illegibilitywasalsoeradicated.
PadlokwasusedtoalesserextentintheEmergencyDepartmentduetothefast-pacednatureoftheworknotbeingconducivetodoctorsleavingtheirpatientstologontoacomputer.
Padlokwasusedinthewardswithmostrequestsbeingforbloodtestscollectedduringroutinephlebotomyservicerounds.
ThePadlokpost-implementationsurveyrevealedonly9%ofrespondentshadtroubleaccessingcomputerstousePadlok.
Issues Therewereconcernsthatmakingtherequestingprocesseasiermighthave
resultedinhigherratesoftestingandincreasednumbersoftestsperpatient,butthisdidnotappeartobethecase.
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Clinicalstaffrevertedtorequestingonpaperformswhenaccesstocomputerswaspoororunavailable.
ThereweretechnicalissueswiththeconfigurationofPadlok-onlyworkstations.HospitalstaffalsorequiredaccesstootherhospitalsystemsconcurrentlywhenusingPadlok,andmedicalstaffpreferredworkstationswithaccesstomultiplesystems.
TheinstallationandmaintenanceofdedicatedpathologytestrequestingworkstationsresultedinadditionaltechnicalandmaintenancedifficultiesfortheITDepartment.
Theprojecthelpedidentifypracticeswhichwereinefficientorunsafeandimproveddocumentationandauditprocesses.
Recommendations 1. Provideaclinicalliaisonandprogrammers/trainerspositions.2. Provideabudgetforequipmentformaintenanceofthesystem.3. Padlokcouldbedevelopedintoapaperlesssysteminoneyear,andnursing
elementscouldbedevelopedconcurrently.4. Explorethemeansbywhichdoctorscanbepositivelyinfluencedduringthe
requestingprocesstoreduceredundancy,andincreaseappropriatetesting.
Key Project Learnings
Keytothesuccessoftheprojectwasaprogrammerwithaclinicalbackgroundinnursingandamedicalregistrartoactasclinicalchampion.
Findingamedicalregistrarfortheroleofclinicalchampionwasverydifficult. TherewereproblemswithtimelinesduetovariousIT-relatedissues. ProblemsinSpecimenReceptionwerenotforeseen,andalaboratoryProject
Officerwasemployedtowardstheendoftheprojecttoaddressthesematters.
Problemsinthephlebotomyareawerenotforeseen,particularlythemanagementofstaffwithnofamiliarityofcomputers.
TheneedfornursingstaffinvolvementinthedevelopmentofPadlokwasnotrecogniseduntillateintheproject.
Doctorswererequestingassaysfordrugstobegiveninthefuture. Allproblemsweresatisfactorilyaddressedwithworkinggroupmeetings.
Areas for Future Consideration
BedsideaccesstoITformultiplepurposes(laboratory,radiology,dischargesummariesetc.)isthekindofinitiativethatwillleadtomoreextensiveuseofon-linepathologyrequestinginthefuture.
Information Extraction from Narrative Pathology Reports on Melanoma (2008)
Description Thispilotstudysoughttodemonstratethatkeyelementsofonetypeofpathologyreport(melanoma)couldbedefinedinastructuredformat.Italsosoughttodemonstratethathardcopypathologyreportscouldbeaccuratelyannotatedbytrainedlinguiststoindicatethecorrectstructuredreportelementstosupporttheautomaticextractionofthoseelements.
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Grant Recipient UniversityofSydney
Aims and Objectives Nospecificaimsorobjectiveswereincludedinthereportalthoughtheexecutivesummarynoted:
Ananalysishasbeenconductedonpathologyreportsofmelanomawiththepurposeofdeterminingifhumanannotatorscanreliablyidentifythecontentsappropriatefordevisingmethodsfortheautomaticextractionofpathologyconceptsneededtopopulatestructuredreports.
The report’s authors stated all project objectives were achieved, although these objectives were not included in the report.
Findings
Linguistscanreliablyproducemoreconsistencythanpathologistsinannotatingalargecorpus*ofpathologyreports.
Thereliabilityoflinguistsbetweeneachotherisconsistentlyhigherthanbetweenthepathologists,orbetweenalinguistandapathologist.
Linguistsmissabout6%ofthetagsannotatedbythepathologist,andthepathologistsmissaboutthreetofiveasmanyassignedbythelinguists.
Thefindingssuggestthatoncelinguistsaretrainedtounderstandthelinguisticfeaturesandextentofpathologyconcepts,theycanreliablyannotateinformationtoaidtheautomaticextractionoftheseconceptsinstructuredpathologyreports.
Thestudyshowedonlythreetagswereinterpretativeandtheother19tagsweredirectlydefinedbycontent.Thisindicatestheymaybereliablyextractedbyautomaticcomputationalthoughitwilltakefurtherresearchtoestablishthisisthecase.
Thestudyalsohighlightedproblematicareasofannotatingsuchalargecorpus.
Furtherrefinementofthetrainingprocessshouldsignificantlyimprovetheperformanceofthelinguiststohavefarfewermisses,andreducetheerrorratebelow3%.
*corpus/corpora:acollectionofnaturallyoccurringlanguagetextchosentocharacteriseastateorvarietyoflanguage
Recommendation 1. Furtherresearchisrequiredtoestablishthereliabilitytowhichthese
conceptscanbedefinedandthereforeannotatedcorrectly.
Key Project Learnings
Morestructuredmeetingsbetweenlinguistsandpathologistswouldhavebeenbeneficialtorevisetheconceptsetbeforeannotationofallreports.
Amorestructuredscheduleofconcepttag-setrevisionswouldhavereducedconfusionandimprovedtagdevelopment.
Thestudyidentifiedissuesabouttheoriginalpathologyreportsthatcouldproveusefulintheeducationofprofessionalpathologistsfortheirreportwriting.
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Follow on Initiatives and Projects
Asecondstageforthisprojectwasundertakentodevelopsoftwaretoautomaticallycompilethesynopticreports(AutomaticCompilationofSynopticReportsfromNarrativePathologyReports(Stage2)(2010Submittedwiththetitle:ThePathologyReporter))
Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter)
Description Thisstudysoughttodevelopasoftwaresystemtoautomaticallyextractinformationfrompathologyreportsforthreetypesofcancerstodisplayinformationinasynopticreportingformat.Itwasdesignedaroundthreereportcategories:melanoma,skincancerandlymphoma.
Grant Recipient UniversityofSydney
Aims and Objectives Thesewerenotspecificallyoutlinedinthereporthoweverthefollowingpointswereextractedfromtheintroduction: tocompletetheconstructionofaninformationextractionenginefor
melanoma toannotateskincancerandlymphomareports tobuildanextractionengineforskincancerandlymphoma tocreateawebsitewhereanyonecouldusetheextractionenginefortesting
theirownreports.These aims and objectives were achieved by this project.
Outcome
ThewebsitewhereanyonecouldusetheextractionenginefortestingtheirownreportshasbeenoperatingsinceFebruary2010andisavailableat:http://hitrl.it.usyd.edu.au/~KDKRWorkbench/spr/cgi-bin/spr.py.
Findings
Lymphomawasmoredifficulttoannotateandwasmorecomplexinitsdescriptionofparticularfeaturesresultinginslightlyloweraccuracyfortheautomaticprocessing.
Theresultshighlightedproblematicareasofannotatingpathologycorpora*. TheeffortofrecognisingtheSNOMEDCTcodesfordiagnoses,andthe
populationofthestructuredreportformelanoma,showthisworkhasthepotentialforimprovingtheautomaticprocessingofprosereports.
Recommendation 1. Itwilltakefurtherresearchtoestablishthereliabilitytowhichthese
conceptscanbedefinedandthereforeannotatedcorrectly.
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Key Project Learning
Thegainsfromthisapproacharelikelytocomefromdiseasereportsthathaveahighfrequencyandaremostamenabletoproducingstructuredreports.
Follow on Initiatives and Projects
Thethirdstageofthisprojectiscurrentlybeingundertaken(AutomaticPopulationofSynopticReportsfromNarrativePathologyReports(Stage3)).
Areas for Future Consideration
Alargercorpora*needstobecollectedfordiseasecategoriesthataremorecomplexintheirpathologytestinganddescriptions.
*corpus/corpora:acollectionofnaturallyoccurringlanguagetextchosentocharacteriseastateorvarietyoflanguage
Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current)
Description Thisprojectbuildsontheworkofthefirsttwostagesandaimstobuildnaturallanguageprocessorsthatwillautomaticallyextractpertinentinformationandpopulateastructuredcancerreport.Thissystemwillenabletheanalysisofnarrativereportstoidentifyandextractkeycontent.
Grant Recipient UniversityofSydney
Aims and Objectives
tobuildprocessorsforthesetofmelanoma,skincancersandlymphomathatcanautomaticallypopulatetheformallydefined,structuredreport
toaddtothesystemtheSNOMEDCTencodingofthestructuredreportelements.
This project is current and the aims and objectives are in the process of being achieved.
Recommendation 1. Duetotheresultstodatewhichshowalessthansuccessfulperformancefor
lymphoma,workonlymphomashouldbeofsecondaryconsiderationinprogressingthisproject.TheextentoffurtherworkonlymphomawillneedtobediscussedwiththeRoyalCollegeofPathologistsofAustralasia(RCPA)andtheQualityUseofPathologyCommittee(QUPC).
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Standardisation of Pathology Terminology and Units (Current)
Description Thisprojectisdevelopingareferencesetofstandardisedpathologyterminologywithguidelinesfortheiruse,andstandardsforunitsofmeasure,tominimisetherisksofvariationintheirusebetweenhealthprofessionalsandpatients.Thedevelopedterminology,unitsandmeasureswillbeabletoberepresentedelectronically.
Grant Recipient RoyalCollegeofPathologistsofAustralasia(RCPA)
Aims and Objectives
todevelopandapprovearevisedsetofstandardunitsofmeasuretoberepresentedelectronically(StandardforUnitsofMeasure)
todevelopandapprovestandardterminologysets(SNOMEDCT,LOINCetc.),includingadvicefortheiruse(AustralianPathologyTerminologySets)
todevelopafullyspecifiedterminologyforthereportingof‘common’biochemistryitemsusedinclinicaldecisionsupport,includingadviceforitsuse(standardisationofcommonbiochemistryitems)
toreviewtheprotocolsforcancerreportingandensureterminologyisavailable,consistentandabletobeusedinelectronicdecisionsupport,includingadvicefortheiruse(terminologyforstructuredcancerreports).
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Pathology Requesting and Reporting – Requester and Consumer Focus Requestingandreportingarekeycomponentsofthepathologyprocessandimpactonthequalityuseofpathology.Thischapterincludes17projects(Table6)whichsoughttoenablemedicalstudentsandtreatingpractitionerstoaugmenttheirknowledgeandpracticeofpathologyrequestingandimproveconsumeroutcomes.Improvedreportingmethodologieswerealsoexplored,andaflow-onbenefitinmanycaseswascostsavings.Oneoftheissuesencounteredwiththesuccessfulimplementationofanumberoftheseprojectswasaresistancetochangeentrenchedpracticesandalackoffundingtoprovidesustainabilitytotheprojectsinthelongerterm.Identifying‘champions’whoshouldideallyholdseniormedicalpositionswasoneconsistentstrategyindentifiedinthisintegratedanalysistochangeentrenchedpractices.Otherissuesencounteredinthisareainclude: projectsinvolvinginformationtechnology(IT)werepronetotechnical
problemswhichincreasedprojecttimeframes lackofpathologytraininginmedicalschools lackofunderstandingbypathologyrequestersregardingtheimportanceof
completingpathologyrequestforminformation.Theseprojectsalsocollectivelyidentifiedinformation,issuesandstrategiesthatcontributedtoanoverallknowledgebasetopromotechangeandimprovefuturepractice.Someprojectswithsuccessfuloutcomesbutwerenotsustainableatthetimeoftheirimplementationmaybenefitfrombeingrevisitedastheirfindingsandoutcomesarestillapplicableinthecurrentenvironment,especiallyastechnologybecomesmoreacceptableasalegitimatehealthcaretool.Otherareasforfutureconsiderationinclude: ReviewtheAUSLABprojects(pages94and96)withaviewtoimplementing
theminstatesoutsideofQueensland. ExploretheoptionsforPersonalDigitalAssistant(PDA)system
implementationinhospitalenvironments. InvestigatetheareasPracticeNursescanassistwithinformationregarding
pathologytestingandpatienteducation. Assesstheviabilityofre-establishingtheQualityUseofPathologyServices
EducationProgram(onpage109)inruralmedicalschools. Reviewtheformatandcontentofpathologyrequestforms. Investigateimplementinganeducationprogramwhichtargetsthemost
importanterrorsoromissionsonrequestforms. Possibledevelopmentofatrainingprogram/modulestobeprovidedto
GeneralPractitioner(GP)RegistrarsandInternationalMedicalGraduates(IMGs),andtheneedforatrainingmodule/s.
Producefactsheetscoveringthearea’shighlightedinrecommendationno.6ofthereportEnhancingtheQualityUseofPathologyforGPRegistrarsandInternationalMedicalGraduates–AssessingtheNeedonpage113.
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Produceafactsheetonantibioticuseandbacteriuriaforalllevelsofmedicalstaff,includingnurses,toempowerthemtodevelopconfidenceinwithholdingantibioticsforasymptomaticpatients.
IdentifyfurtherpotentialusersforiNvestigate. Developastandardnationaldefinitionof‘appropriate’pathologyuse.[alt=“ThefollowingtableliststheseventeenprojectnamesandgrantrecipientsunderthePathologyRequestingandReporting–RequesterandConsumerFocustheme”] Project Name Grant Recipient/s 1 GuidelinesforPatient/ConsumerAccesstoPathology
TestReports(2001)QualityUseofPathologyCommittee(QUPC)
2 AUSLABRetestIntervalTrialProject(2003) QueenslandHealthPathology&ScientificServices
3 AUSLABRetestIntervalProject(2004) QueenslandHealthPathology&ScientificServices
4 HomeMonitoringofWarfarinTherapyinChildrenusingtheCoaguchekTMPointofCareINRMonitor(2003)
TheRoyalWomen’sHospitalandtheRoyalChildren’sHospital
5 FacilitatingBestPracticePathologyUtilisationbytheUseofHand-HeldDecisionSupportDevices(2004)
FlindersMedicalCentre
6 ImprovingGPAccesstoandUseofRetrospectiveandCurrentPathologyDatatoIncreaseDetectionofEarlyDiabetes(IGTandIFG)inGeneralPractice(2005)
FremantleRegionalGPNetwork
7 QualityUseofPathologyServicesEducationProgram(2006)
UniversityofSydney
8 InvestigationintotheReasonsforIncorrectorIncompletePathologyRequestForms(2008)
RoyalNorthShoreHospital
9 EnhancingtheQualityUseofPathologyforGPRegistrarsandInternationalMedicalGraduates–AssessingtheNeed(2009)
UniversityofAdelaide
10 EffectofaStructuredMicrobiologyLaboratoryReportonAntimicrobialPrescribingforAsymptomaticBacteriuriainElderlyFemales(2010)
FlindersMedicalCentre;SouthAustraliaPathology
11 IdentifyinghowElectronicDecisionSupport(EDS)inComputerisedPathologyOrderEntrySystemscanImprovePathologyPractice,RationalOrderingandPatientOutcomes(2010)
UniversityofSydney
12 TheImpactoftheImplementationofElectronicOrderingofPathologyRequestingandtheQualityandEffectivenessofHospitalPathologyServices–BuildingaRobustEvidenceBaseandBenefitsFrameworkforSuccessfule-HealthDiffusions(Current)
UniversityofNewSouthWales
13 ComputerAssistedPatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase1(iNvestigateProject)(2010)
UniversityofNewSouthWales
14 iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase2(2011)
UniversityofNewSouthWales
15 iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations(Current)
UniversityofNewSouthWales
16 EncouragingQualityPathologyOrderinginAustralia’sPublicHospitals(2011)
NationalCoalitionofPublicPathology(NCOPP)
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17 EffectiveCommunicationofPathologyResultsinRequestingPractitionersandConsumers(Current)
UniversityofMelbourne;DianellaCommunityHealth;RoyalCollegeofPathologistsofAustralasia(RCPA)
Table 6: Reports summarised for Pathology Requesting and Reporting – Requester and Consumer Focus
Guidelines for Patient/Consumer Access to Pathology Test Reports (2001)
Description Thispapersetsoutguidelinesforpathologistswhereaconsumer/patientdecidestoseekaccesstopathologytestreportsdirectlyfromthepathologyprovider.TheywerewritteninresponsetoamendmentstotheCommonwealthPrivacy Act 1988whichcameintoforceon21December2001.TheseamendmentsallowedaCommonwealthstatutorybasisforpatients/consumerstorequestandobtainaccesstohealthinformationbythemselvesthatisheldbyorganisations,includingfrompathologists.TheyextendedthistotheprivatesectoraslegislationwasalreadyinplaceinsomeStatesandTerritoriesforprovidingaccesstomedicalrecords.Eachorganisationholdingpersonalinformationwasthereforerequiredunderthelegislationtohaveproceduresinplacetoaccommodatethesenewrequirements.
Grant Recipient QualityUseofPathologyCommittee(QUPC)
Aim
toprovideguidelinesforpathologistswhereaconsumer/patientdecidestoseekaccesstopathologytestreportsdirectlyfromthepathologyprovider.
This aim was achieved by this project.
Findings
TheQUPCsupportsthegeneralprinciplethatpatients/consumersshouldconsultwiththeirtreatingpractitionerbeforedirectlyapproachingthepathologyproviderforaccesstopathologytestreports.
TheQUPCrecognisesthattheprimaryadvicerelationshipisbetweenthepatient/consumerandtherequestingpractitionerwhoisinthebestpositiontointerpretthepathologytestreportswithinthecontextofthepatient’s/consumer’shistory,andallotherinformationincludingotherdiagnosticprocedures.
Incircumstanceswherethepatient/consumerdecidestoseek(obtain)directaccesstopathologytestreports,theQUPCencouragespathologyprovidersandrequesterstofollowtheprocesssetoutinrecommendationstwotofivebelow.
Recommendations 1. Thepatient/consumershouldalways,inthefirstinstance,approachthe
requestingpractitionerforaccesstotheirpathologytestreport.
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2. Subjecttothepolicyandprocedureswhichithasputinplacetodealwiththenewlegislativerequirements,wherethepatient/consumercontactsthepathologyproviderdirectlyforaccesstothepathologytestreport,thepathologyprovidershouldrecommendthatthepatient/consumercontacttherequestingpractitioner.Inmostinstances,therequestingpractitionerwillprovideacopyofthepathologytestreporttothepatient/consumerwithanappropriateinterpretation.
3. Ifthepatient/consumerrequestsaccesstothepathologytestreportfromthepathologyprovider,thenthepathologyprovidershouldconsultwiththerequestingpractitionertoascertainwhetherornotacopyofthepathologytestreportshouldbeprovidedbythepathologyproviderdirectly. Iftherequestingpractitioneragreesthatthepathologyprovidershould
provideacopyofthereport,thenitisrecommendedthatthepathologistgivesaprintedcopyofthereporttothepatient/consumerandsendsacopytotherequestingpractitionerwithadatednotationthatacopyofthereporthasbeenprovidedtothepatient/consumer.
Thepathologistshouldkeepdocumentationofthediscussionwiththepatient/consumer.Ifthepatienthasanyquestionsconcerningtheirtestresults,thepathologistshoulddirectthepatient/consumertoraisetheseissueswiththerequestingpractitioner.
If,afterdiscussionwiththerequestingpractitioner,thepathologistdeterminestheresultsshouldnotbeprovided,thenthepathologistshouldadvisethepatient/consumerthattheresultsarebeingwithheld.Thereasonsfornotprovidingthepathologytestreportdirectlytothepatient/consumershouldbeconveyedtothepatient/consumer,preferablyinwritingandsignedbythepathologist.Reasonsforwithholdinghealthinformation,includingpathologyresults,asprovidedforinthePrivacyAct,include:
o aseriousrisktothelifeorhealthoftheindividualo thattheprivacyofothersmaybeaffectedo thattherequestisfrivolousorvexedo existingoranticipatedlegalproceedingso thataccesswouldbeunlawfulo thatdenyingaccessisrequiredorauthorisedbyorunderthelawo lawenforcementandnationalsecurityreasonso commerciallysensitiveevaluativeinformation.
4. Ifthepathologyproviderdeterminesthatthepathologytestreportshouldnotbereleaseddirectlytothepatient/consumer,forreasonsthepathologyproviderconsiderstobeinaccordwiththePrivacyActandanyotherrelevantlegislation,andthepatient/consumerstilldesiresacopyofthetestresults,thenthepathologistshouldadvisethepatient/consumertosubmitawrittenrequesttotherequestingpractitioner.(Thisisrecommendedonthebasisthattherequestingpractitionerislikelytobethebestpersontodeterminewhethertheprovisionofthepathologytestreporttothepatient/consumerwouldconstituteaseriousthreattothelifeorhealthoftheindividual).
5. Ifthepathologyproviderandtherequestingpractitionerrefusetoprovideacopyofthepathologytestreporttothepatient/consumer,thepatient/consumercanseekredressthroughtheHealthCareComplaints
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Commissionorthecomplaintmechanismprovidedunderthenewprivacylegislation.
AUSLAB Retest Interval Trial Project (2003)
Description TheAUSLABlaboratoryinformationsystemisimplementedin34publicpathologylaboratoriesacrossQueensland.Over20,000testsareorderedperdayonthissystem.Certaintestsarefrequentlyrepeatedonthesamepatientwithinaninappropriatelyshorttimeperiod,mostlybecausetherequestingdoctordoesnotrealisethetesthasalreadybeenrequested/performed.TheRetestIntervalfunctionalityinAUSLABwastrialedandactivatedforthreemonthsatRockhamptonBaseHospitalandLoganBaseHospitalforthefollowingtestsjudgedtobethemostsuitableforthisintervention: antinuclearantibodies(ANA) folate glycosylatedhaemoglobin(HbA1c) HepatitisCantibody(HCVAb) ironstudies lipids(cholesterol,triglycerides,+/-HDL) syphilisserology(RPR,TPHA) thombophiliascreen Thyroidfunctiontests(TFTs) VitaminB12.
Grant Recipient QueenslandHealthPathology&ScientificServices(QHPSS)
Aims
toimplementtheretestintervalfunctionalityinAUSLABtopreventoverorderingofpathologyrequests
tonotifymedicalstaffiftheirpathologyrequestincontraindicatedduetorecentprevioustest.
The first aim was achieved by this project although the report did not specifically state if medical staff were notified if their pathology request was contraindicated.
Outcomes
Theprojectsaved$4,494.90overthreemonthsbyrejectingpathologyteststhathadalreadybeenordered.
Theprojectwasverysuccessfulinstoppingpathologyre-orderingfortestsalreadyorderedwithinapre-determinedtimeframe.
Themostcommonpathologytestsrejectedusingtheintervalwere:o TFTs 5.8%o HbA1c 12.0%o lipidprofiles 8.9%.
Thebenefitsrealisedwere:o a6.2%decreaseintheamountofinappropriateorderingofthe
pathologytestsselectedinthetrial
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o improvedcommunicationresultinginincreasedawarenessbetweenrequestorsandpathologists
o changestopathologyorderingpatternsbyseniorclinicianso alterationtochemistrypathologyorderingcriteriaofrenalpatientsat
RockhamptonBaseHospital.o significantadditionalrequestsforsupplementaryteststobeaddedto
theintervals. Thenumberof“Retests”decreasedoverthethreemonthsofthetrialatboth
LoganBaseHospitalandRockhamptonBaseHospital. Thereweretworeportedcasesofmedicalstaffphoningthelaboratoryand
requestingadditionaltestingonasamplethathadoriginallybeenrejectedbytheretestalgorithmatLogan.
Findings
Usingthecurrenttestcodesintheretestprojectwouldsaveanestimated$18,000peryearinunnecessarypathologyorderingatRockhamptonandLogandistricthealthservicesin2003.Anestimated$360,000peryearwouldbesavedinunnecessarypathologyorderingifthesewereexpandedtothewholeofQueenslandHealth.Ifextratestcodeintervalswereaddedthepotentialsavingcouldbegreaterthan$500,000peryear.
Thereasonstestswerere-orderedcanbesummarisedinthreemainareas:o medicalstaffwereunawarethetesthadalreadybeenorderedby
anotherclinicianduetonothavingaccesstoAUSLABterminals,theinformationwasnotrecordedinthepatient’schartandthelackofclinicalinformationsystemorwardorderingsystem
o juniormedicalstaffattemptingtobesuretheyhadorderedALLtestsrequiredbytheirconsultant.Thismaybeduetoacultureinsomeclinicalenvironmentswerejuniormedicalstaffarereprimandedfornotorderingtheappropriatepathologytests
o clinicalpracticesthatorder“defaultordering”incertainareas.Forexample,renalpatientshavelipidsorderedwhenanyotherchemistrytestisordered.
Recommendations 1. AsubsequentprojectissupportedtoimplementtheAUSLABRetestInterval
functionalityatallQHPSSlaboratories.2. Investigatetheoptionofexpandingtherangeoftests.3. AreviewoftheprojectatLoganBaseHospitalidentifiedthefollowing
requests(subjecttofindingforaprojectofficertoexpandtheretestalgorithm)bymedicalstaff:
a. additionaltestinglength’sbeaddedtothetestcodesusedinthetrialb. additionaltestsbeaddedtotheAUSLABalgorithmc. acentralcontactbeprovidedformanagingchangesandnewrequests.
Key Project Learnings
SeniorclinicalstaffatRockhamptonandLoganapplaudedthetrial. Therewerefiverequestsbyotherdistrictstoimplementthisfunction. TherewasnosignificantimpactonotherQHPSSlaboratories.
Follow on Initiatives and Projects AUSLABRetestIntervalProject(2004).
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AUSLAB Retest Interval Project (2004)
Description ThisprojectextendedtheAUSLABretestintervaltrialprojectto33QueenslandHealthlaboratorieswithover25,000testsorderedperdayonthissystem.
Grant Recipient QueenslandHealthPathology&ScientificServices(QHPSS)
Aim
toimplementaprocessforinterceptinginappropriatepathology. This aim was achieved by this project.
Outcomes
QHPSSimplementedtheRETESTintervalsysteminall33laboratories,andasaresultallpublicQueenslandHealthrequestsforteststargetedbytheprojectweresubjectedtotheRETESTalgorithm.
AdditionaltestscodestotheRETESTintervalalgorithmwereimplemented. Anacceptedandapprovedmethodfortheinterceptionofinappropriate
pathologyordershasbeenimplementedacrossQueenslandHealth. TheRETESTalgorithmisnowanacceptedbusinessprocessforQHPSSin
everyhospitalacrossQueenslandHealth. Developmentofabestpracticeprocessforselectionofpathologytestsby
medicalstaff. DevelopmentofalaboratoryprocedureforteststhataresubjecttoaRETEST
IntervalinAUSLABincludingaprocesstoassessandanalysetheteststhathaven’tbeenorderedwithintheacceptableretestinterval.
Developmentofasurveytooltomeasuretheextentofunnecessaryrepeatorderingacrossthestate.
AwarenessandtraininginappropriatepathologyorderingandtestingforQHPSSandmedicalstaff.
Extractionofdatathatmeasurestheutilisationofpublicpathologyservices. PresentationshavebeenmadetootherAUSLABsitesacrossAustraliaduring
annualAUSLABusergroupmeetings.
Findings
TheprojectwassavingconsiderableamountsofmoneyeachmonthforQueenslandHealth.Directsavingsatthetimeofthereportwerealmost$150,000,andabove$10,000permonth.
DatafromallsitesinvolvedintheprojectshowedtheretestfunctionalityhasseensomereductionintheoveralltestcodesorderingusedintheRETESTproject,althoughthiswasnotuniformacrossallsites.Manyexternalfactors,suchashospitalactivity,mustbeanalysedbeforemoreformalconclusionscouldbedetermined.
Analysisindicatedtheliverfunctiontest(LFT)wasover-ordered;8%ofallofthesetestsinQueenslandwereonthesamepatientonthesameday.
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However,theChemicalPathologyCommitteedidnotapproveofthistestcodebeingaddedtotheintervalalgorithm.
Thyroidfunctiontest(TFT),glycosylatedhaemoglobin(HbA1c)andcholesterol(lipids)werethemostcommonlyover-orderedorrepeatedtestsintheproject.Requestsforthesetestsweresuccessfullyinterceptedbythisproject.
AlmostallsitesexperiencedareductioninthenumberoftestsrejectedasaresultoftheRETESTprogram.IpswichexperiencedamarkedincreaseinthenumberofRETESTsorderedinthepathologydepartment,withnoexplanationabletobefoundforthisincrease.
Key Project Learnings
TherewasoneformalcomplaintreceivedbytheprojectstafffromaseniormedicalconsultantwhichwashandledbytheDirectoroftheDivisionthetestcameunder.AconfigurationchangewasmadetothetestreporttoindicatethetestwassubjectedtoaRETESTinterval,eventhoughthisisalsoindicatedonrejectedreports.
ThereweredifficultiesexperiencedinengagingsomeareasofQHPSS,includingadditionalnewtestsforconsideration.
TheprojectwasperceivedtobeapoorbusinessdecisioncostingincomefromareaswithQHPSS.
ShortagesinqualifiedAUSLABconfigurationstaffimpactedonthespeedthatnewtestscouldbeimplemented.
Aprojectofthistypemustbedrivenbytheclientsofthepathologyservice(i.e.doctors)notbusinessmanagers,accountantsorpathologists.
Itwasthesupportoftheseniorcliniciansateachsitethatencouragedalmostallotherclinicianstoacceptthechangestothepathologyorderingprocess.
Complaintsandeducationmustbehandledcorrectlyandpromptlytoensuresmoothacceptanceduringtheimplementationphase.
GettingengagementfromthelargestfacilityinQueenslandHealth(RoyalBrisbaneandRoyalChildren’sHospitals)foranimplementationmeetingwasdifficultduetoconstantchangeindistrictmanagementandmedicaladministration.
Whentheprogramwasacceptedinsomeofthemajorhospitalsites(e.g.ThePrinceCharlesHospitalandThePrincessAlexandraHospital)thenothersitesaroundQueenslandbecameverywillingparticipantsintheproject.
Difficultieswereexperiencedingainingapprovalfornewtestsforthealgorithmfromchemicalpathologyandhaematology.ThereductionintheRETESTIntervalforTFTandHbA1cwasunfortunatebutacceptedasthedecisionwasmadebythecommitteewithinQHPSSforexpertadviceonchemicalpathologytesting.
TheimplementationoftheNewTests–MicrobiologyTestcodeURINE-requiredmodificationtoworkpracticeinthelaboratories.
Area for Future Consideration
ReviewtheAUSLABprojectwithaviewtoimplementingitinotherstates.
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Home Monitoring of Warfarin Therapy in Children using the CoaguchekTM Point of Care INR Monitor (2003)
Description PreviousresearchperformedbytheRoyalChildren’sHospital(RCH)hadshowntheCoaguchekTMINR(internationalnormalisedratio) monitorwasreliableandaccuratewhenusedtomonitorchildrenwithinthehospitalenvironment.Thisstudyaimedtodetermineifthisoutcomewasachievableinthehomeenvironment.AllchildrenreceivingwarfarintherapymanagedbytheHaematologyDepartmentoftheRCHwereinvitedtoparticipate.Sixteenfamiliesrespondedandallwereacceptedintothestudyasfundswereavailableforuptotwentychildren.Fourteenfamiliescompletedalloftherequirements.
Grant Recipients TheRoyalWomen’sHospitalandtheRoyalChildren’sHospital
Aim
todeterminethesafetyandefficacyofahomemonitoringprogramfacilitatedbyacomprehensiveeducationpackagetofamilies.
This aim was achieved by this project.
Outcomes
INRsperformedbyparentsathomecorrelatedverywellwithINRsperformedinthehospitalbydedicatedpathologycollectionstaff.
ThehomeINR(H-INR)resultswouldhaveproducedadifferentmanagementplanthanthecontrolINR(C-INR),takenateverysecondtestpoint,onthreetest-pointsoutofthetotalnumberperformed.
Allparentscompletedtheeducationandtrainingprogramassociatedwiththisprogram.
Findings
28%ofparentsunderstoodtheirchild’sindicationforwarfarintherapyatthecommencementoftheeducationprogram,whichincreasedto93%atthecompletionoftheprogram.85.7%maintainedthisknowledgeatthesix-monthreassessment.
Mostparentsratedtheprogram10outof10,andallstatedtheywouldliketocontinueperformingINRtestsontheirchildintheirhome.
TheestimatedtotalcostofperforminganINRathomeis$13.56plus10minutesofparentaltime.
TheestimatedtotalcostofperforminganINRinhospitalsettingsis$21.96plusaboutonehourormoreofparenttimeaswellascommunityimpacttime.
Homemonitoringofwarfarintherapyisassociatedwithreducedcostcomparedtohospital-basedmonitoring.
Thereisnoavenuetosupportthecostofongoinghomemonitoringofwarfarintherapyanditdoesnotreceiveanyformoffunding.
Homemonitoringofwarfarintherapyisunlikelytobewidelyused,despitethesignificantsavings,unlessinfrastructureisofferedtosupportthisactivity.
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Recommendation 1. Developa“self-monitoring”programwherepatientsofsufficientageare
taughttoperformtheirowntests.
Key Project Learning
SeveralparentsnotedtheyhadearlyproblemsgettingasufficientsizeddropofbloodtoperformtheINRtest.Thisproblemcanbeovercomethrougheducationabouttechnique.
Follow on Initiatives and Projects
FurthertestingofthesafeuseofPOCTdevicesaspartofthePointofCareTestinginGeneralPracticeTrialhttp://www.health.gov.au/internet/main/publishing.nsf/Content/health-pathology-poctt-index.htm.
Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)
Description Thisstudysoughttoprovethatthequalityuseoflaboratorytestingcouldbeimprovedbytheuseofanelectronicclinicaldecisionsupportsystemforrequestingdiagnosticlaboratorytestswhichprovidedtheuser,atthetimeofclinicaldecision-making,with:
o bestpracticetestselectionfortheclinicalproblemo relevantpasttestresults.
Grant Recipient FlindersMedicalCentre
Aims
toinvestigateiftheutilisationoflaboratorytestscouldbeimprovedbyrequestersusingwireless-enabledpersonaldigitalassistants(PDAs)that:
o providedpasttestresultso recommendedtestsandguidelinesonexcessivefrequencyofrepeat
testing‘atthebedside’o identifiedfeaturestoencouragetheaboveoutcome
toencouragetheuseofbestpracticetestutilisationbydevelopingsoftwarethat:
o utiliseswireless-enabledPDAstoprovidemedicalstaffwithelectronicsupportatthetimeofclinicaldecision-making
o integratesbestpracticetestselectionandrelevantprevioustestresultswithminimumre-testintervalsforeachselectedpatient
o downloadsthefinaltestselectiontolocallygenerateapathologyrequest.
These aims were achieved by this project.
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Objectives
toincreaseknowledgeaboutthedevelopmentandimplementationofintelligentelectroniccommunicationbetweenpathologyrequestersandproviders
toidentifythosefeaturesthatwillfacilitatebroadapplicationanduseracceptanceofthemodeltoimprovepathologyutilisation
Path-Pilot System toidentifysuitablewirelesstransmitterandPDAdevices toidentifysuitablecommercialsoftwaretoestablishcommunication
betweenhospitalserversandPDAs todesignPDAscreenstofacilitateuserrequirementsandworkflow tocreatesoftwaretogeneratePDAscreens,captureanddisplaypatientand
pathologydatafromhospitalserversandrecorduseractivityTrials todesignclinicalcondition‘trees’andassociatedrecommendedtests toobtainclinical/laboratoryconsensusfortestminimumre-testintervals toobtainparticipationinpilottrialsbymedicalstaffinageneralmedicine
unit tocollecttestrequestingactivitydatawith/withoutthePath-Pilotsystem.These objectives were achieved by this project although wireless reliability problems, thought to be associated with mandatory encryption requirements, precluded more extensive test utilisation data within the project timeframe.
Outcomes Implementation PDAswereprovidedtogeneralmedicineinterns,residentmedicalofficers
(RMOs)andregistrarsworkinginoneormoreofthewardswithwirelesscoverage.UsersweretrainedintheuseofthePDAandtheprojectsoftwaresystem(Path-Pilot).ThesoftwarewasupdatedwiththenamesofnewuserssothePDAwas‘personalised’foreachuser.Intheeventofhardware/softwareproblems,usershadaccesstotechnicalsupportfromaprojectteammemberviaadedicatedpager.
Theuserselectsthepatientofinterestbyasinglestylustaponthescreentoviewthetestresultsuploadedfortheselectedpatient.Anupperscrollablepaneldisplayedthedatesandtestmnemonicsofresultsavailableforviewing.Theselectedtestdatawasdisplayedonscreeninacumulativeformat,withreferencevaluesalsodisplayedandabnormalvaluesdisplayedinred.
Biochemistry,haematology,immunology,pharmacologyandmicrobiologyresultswereincludedinthetrial,whiletransfusionmedicineandhistopathologywerenotincludedinthesystem.
Teststoassistwithaninitialdiagnosticinvestigationcouldberequestedviaascreen(called?Diagnosis)thatdisplayeda‘tree’ofclinicalproblems/conditionsrelevanttothegeneralmedicineunit.Eachclinicalproblem/conditionwasassociatedwithalistoftestsjointlyrecommendedbytheheadofgeneralmedicineandthepathologyservice.
TherewasaRoutine Managementoptionforpatientswhorequiredon-goingmanagement.
ByApril2004,thebasicsystemdevelopedhadthecapabilityto:
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o utilisewirelesstechnologytodownloadthebasicidentificationdetailsofgeneralmedicalinpatientsallocatedtoaselectedwardorclinicalunit(surname,givenname,unitrecordnumberandbednumber)toPDAs
o downloadanddisplayrecentpathologytestresultsforaselectedpatient
o providerecommendedbestpracticetestingforclinicalconditionsselectedfromclinicalconditiontrees
o allowfurtherteststobeselectedfromthelaboratorymenuo suppressrecommendedoraddedtestsiftherewereconflictswith
minimumre-testintervalso localprintoftestrequestformswirelessly.
Anydeficitsinthesystem,suchastestsmissingfromthemenu,couldbeovercomebywritingonthegeneratedrequestforms.
Eachtrialperiodlastedtwotofourweeks,dependingontheleveloftechnicalproblemsandusercooperation,withfeedbackobtainedbyface-to-facedebriefsbasedonaquestionnaire.Thiswasfollowed,wheretechnicallyfeasible,byanupgradeoffeaturesforwhichtherewasareasonablelevelofuserconsensus.ThreeofthesedevelopmentcycleswerecompletedintheperiodMay-December2004involvingatotalofapproximately20medicalstaff.
ThemajorityoftestsinthePath-Pilotsystemwereassociatedwith‘minimumre-testintervals’(MRI)whichweredefinedasthetimeperiodwithinwhicharepeattestwasveryunlikelytobeofclinicalordiagnosticvalue.
Ofalltheuserselectedanduseraddedtests/panels(2835),170(6%)didnotproceedtoalaboratoryrequestduetoMRIguidelines,andafurther147(5.2%)didnotproceedtoalaboratoryrequestduetotheuserde-selectingthetest.Thetotalnumberoftests/panelsreinstatedbyuserswas246(8.7%).
ThelimiteddatasuggestedthatPDAswereusedtoviewtestresults(62%)moreoftenthattorequesttests(38%).
Costs Evenaminimumreductionof5-6%oftestrequestingrepresentsa
significantmarginalcostsavingformediumtolargelaboratories,andforMedicarepathologyservicerebates.
Issues ThePath-Pilotsystemincorporatedaclinicalconditionstreedesignedbyan
EmergencyDepartmentconsultant,buttodateorganisationalfactorshaveprecludedatrial.
Thelevelof‘inappropriate’repeattestingwassmallrelativetolevelscommonlyreportedinlargestudieswhichmaybedueto:
o theuserswerewell-versedinappropriatetestutilisationo participationinthetrialscausedachangeinusualrequesting
behaviour.Thiswillbeexploredwhentheoriginalpre-andPath-Pilotinterventionisundertakenwhentheconnectivityproblemsareresolved.
Feedback
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Feedbackindicatedthat?Diagnosiswasmostusedwhenpatientswereintheadmissionwardandbeingworkedup,whiletheRoutine Managementoptionwasusedfortheongoingmanagementofalreadydiagnosedpatients.
AlltrialuserswerepositiveabouttheusabilityofPDAsandgenerallyconsideredtheirusewouldberoutineinthenearfuture.
Allusersfoundthealertsforminimumretestintervalsuseful.Severaluserssuggesteditwouldbeusefultohaveselectablepop-upstoprovidemoredetailedinformationabouttestMRIs.
Therewasamarkedcontrastinuserhabits.Someinternsusedthemonwardroundswhilesomebatchedrequestsattheendoftheday.
Allusersfoundflaggingofunnecessaryrepeattestshelpful(MRIs). Bothspecimencollectionnursesandlaboratoryspecimenreceptionstaff
reportedthattheyfoundtheprintedrequestformstobeasignificantimprovementtotheirregularforms,citinglegibilityoftherequester’sidentity,100%completionofwardlocation,dateofrequest,dateofrequiredcollectionandtestsrequested.Aformalsurveywasnotundertaken.
AwardpharmacistexpressedinterestintriallingaPath-PilotPDAtoaccesspathologyresultsatthebedsidewhenprescribing.
Findings
Valuableinformationwasobtainedconcerninguserprofiles,pathologydecisionsupportpreferencesandpathsforfurtherdevelopment.
Thebasicconceptofprovidingmobilitywiththeabilitytoaccesstestresultsandrequestlaboratorytestswaswellreceivedandviewedasbecominganadditionalworktoolinthenearfuture.
LimiteddatacapturedduringtrialsindicatedthePath-Pilotsystemcanimprovetestutilisation.
Thedegreeofvalueofthesystemdependedontheuserroleintheclinicalunitsandtheworkpatternoftheuser/unit.
ThemajorityofuserscitedthefollowingadvantageswiththePath-Pilotsystem’sabilitytoviewresults:
o rapidaccesstoresultsduringwardroundso noneedtoleavewardroundstoaccessthelatestresultsfrom
desktopsinthewardstation/officeo theabilitytoreviewpatientresultsattheendoftheshiftwithout
waitingtoaccesswarddesktopso theabilitytocheckurgenttestresultswhenabsentfromthepatient’s
ward. Therewasaclearpositiveimpactontestutilisationthroughtheuseofthe
Path-Pilotsystem,althoughitwasnotclearifthiseffectwouldbesustainedinthelongterm.
UptakeofthePath-Pilotwillbegradual,andgenerallyparallelincreasingsystemreliabilityandpeeruse.
Userfeedbackclearlyidentifiedthatacriticalfactortouptakebymedicalstaffinahospitalenvironmentistheextenttowhichconvergenceofbothinformationsourcesandcommunicationcanbeachieved(asoutlinedintherecommendationsbelow).MostusersviewedthePDAasafuturemulti-functiontoolthatwouldcontributetoimprovingtheireffectivenessandefficiencyinclinicalwork.
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Thefrequencyofuseclearlyreflectedthehierarchyoftheclinicalusers,withjuniorstaffbeingtherelativelyhighusers,andregistrarsbeinginfrequent‘one-off’users.Thelattergroupreportedthisfunctionwasofpositivevalue.
DifferentviewswereexpressedintermsofthePDA’svalueforworkactivities.
Recommendations 1. Suggestionsforfurtherdevelopmentofthepathologymoduleinclude:
a. theabilitytoentertestrequestsforspecifiedpatientsduringwardrounds,andholdpendingreviewandorderingattheendofashift
b. expandrequestingcapabilitytootherspecimentypese.g.faeces,pleuralfluids
c. includemorediagnosticallytargetedtestpanelsintheRoutineManagementoption,e.g.‘bone’,‘stroke’,‘pneumonia’,‘septic’,‘diabetic’
d. theabilitytocustomiseclinicalproblemsliststoprofiletheuser’sclinicalunitsuchason-goingmanagementtestingforclinicalproblemsasopposedtodiagnosticwork-uptestingasdoneforanadmissionwork-up
e. theoptiontoincreasecumulativeresultsdisplaybyhavingreferencevaluesas‘pop-ups’,orL/Rscrolling
f. accesstoelectroniclaboratoryhandbookg. a‘pop-up’optiontoviewspecimencollectionrequirementsh. afieldforprovidingtimesfordynamicfunctiontestingi. afieldforprovidingpatientstatuse.g.fasting.j. increasetestmenuentriestocaterforcommonnamevariantse.g.
FBE/CBP,ammonia/NH3etc.k. theoptiontocustomisethetestmenue.g.commonesttestsattop,
alphabetic,commonestofeachlabattopetc.l. providediagnosticpathwaysforinvestigatingspecificconditionsm. providelistsofcausesofabnormaltestsaccessibleselectablefroma
pop-uplistfromtestresult.2. SuggestionsforfurtherdevelopmentofPDAfunctionalityinclude:
a. accesstoradiologyreportsanddischargesummariesb. accesstoclinicalpathwayprotocolsc. accesstoPath-PilotmoduleonownPDAsd. convergehospitalpagersystemtoPDAe. accesstocommonlyusedriskpredictorsoftwaref. accesstopersonalsubscriptionclinicalinformationdatabasesg. accesstohospitalintranet,staffdirectory,medicalofficershandbook
etc.3. ThereisaneedtoupgradetheactivityauditfunctionwithinthePath-Pilot
softwaretoenablediscriminationbetweenuseofclinicalconditiontreesandroutinemanagementoption.
4. ThereisaneedtoautomaticallycapturemoredataonthetestscapturedbyMRIguidelines,particularlybywhichoptiontheywerepresentedforuserreview.
5. Manyuserssuggestedthatadditionalsupporttoolsthatprovidedpathologyinformation,suchasdiagnosticpathwaysandcausesofabnormaltests,wouldbevalued.
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Key Project Learnings Users Nearlyallclinicalparticipantswerepositiveabouttheconceptofcombining
pathologydecisionsupportwithmobility,andfoundtestrecommendationsandminimumre-testintervalalertstobeofvalue.
Themajorityofusersconsideredthepersonaldigitalassistantswillincreasinglybecomeroutinemulti-purposetoolsintheirclinicalworkenvironment.
InternsandRMOsarerotatedthroughclinicalunitseveryeighttotenweeksatFlindersMedicalCentre.ItwasfoundtobeimportanttointroducethePath-Pilotsystemtomedicalstaffatthecommencementofarotationotherwisetheylearnedtousethenormalpaper-basedtestrequestingsystemandweregenerallyreluctanttochangetheirworkpracticespart-waythroughtheirclinicalattachmenttotheunit.
Severalparticipantsfelttheirworkloadsprecludedfullparticipationinthetrial.
Thedevicewasdifficulttocarrycomfortably,especiallyforfemalesiftheydidn’thavepocketsand/orbelts.
Information Technology (IT) Wirelessreliabilityproblems,thoughttobeassociatedwithmandatory
privacyencryptionrequirements,precludedmoreextensivetestutilisationdatacollectionwithintheprojecttimeframe.
Thedebriefingsrevealedageneraldislikeof“computing/ITgadgets.” Bringingtogetheravarietyofcomputingsystemsandsoftwarecoveringthe
PDAitself,wirelesstransmissionandcoverage,hospitalserversandinformationsystems,andprivacyrequirementsinvolvingoff-siteDepartmentofHealthserversposedproblemsthattooksignificantlylongertoresolvethanexpected.
Therewereproblemswithfirst-trywirelessconnectionbyPDAs. Thetechnicalproblems,particularlyrelatedtoconnectionreliability,
stretchedthegoodwillofbusyjuniormedicalstaffforalargepartoftheproject.
WirelessusesignificantlydrainsPDAbatterypowerandconnectionisgenerallylostwhenpowerfallsbelow30%.Thiswasaproblemforsomeusers,butnotforothers.
Project Design and Implementation Itwasclearintheearlyphaseoftheprojectthattwotothreemedicalstaff
andabout20inpatientsinthegeneralmedicineunitco-locatedwiththeRenalUnitwouldprovideinadequatedataexposurefordevelopingthepilotsystem.Itwasthereforeexpandedtoengageallinterns,RMOsandregistrarsinthegeneralmedicineunitworkingacrossthreeinpatientwards.
FlindersMedicalCentrealsounderwentacontinuousperiodofchangein2004whichcauseddisruptiontothePath-Pilottrialsanddatacollectionwhenmedicalstaffandpatientsmovedtoareasnecessitatingthere-locationofthewirelesstransmitter.
ThereturnrateoffeedbackquestionnairesaboutthePath-Pilotsystemwasverylowatthebeginningofthetrial,sofeedbackwaschangedtoaface-to-faceinterviewbasedaroundthequestionnaire.
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Thestudyoriginallyaimedtocomparetestutilisation(choiceandvolume)bymedicalstaffusingboththenormalpapertestrequestsystemandPath-Pilot.Thisapproachwasconfoundedby:
o lessthan100%reliabilityofPDAwirelessconnectivityatfirstattempt,andtimetakentore-establishconnectivity,causedsomeuserstonotfullyparticipateinthetrials
o workpressuresofjuniormedicalstaffcausedsomeuserstoparticipateirregularly
o re-structuringofward/clinicalunitlocationsandpatientprofileso personaldislikeofelectronic‘gadgets’byseveralusers.
ThecombinedeffectofthesefactorswastopreventactiveusersbeinglocatedinthesameclinicalunitforsufficienttimewithsatisfactorilyoperationalPDAstoenablesufficientcollectionofdatatoallowmeaningfulstatisticalcomparisons.ItwasthereforedecidedtocollectallactivitydatageneratedbyuserswhenutilisingPath-Pilotregardlessofwardlocationandperiodofactivity.
Follow on Initiatives and Projects
PossiblefurtherfocusonelectronicdecisionsupportwilloccurunderthePathologyFundingAgreement.
Area for Future Consideration
ExploretheoptionsforPDAsystemimplementationinhospitalenvironments.
Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005)
Description Thisprojectsoughttolookateducationstrategiesforimprovingthedetectionandmanagementofpre-diabetesingeneralpractice.
Grant Recipient FremantleRegionalGPNetwork
Aims and Objectives
establishcurrentandbestpracticeRequest-Test-Reportpracticeandidentifygapsfromboththepathologylaboratoryandthegeneralpractitioner(GP)
establishthebasisforGPlearningwhichwillenablethemtoimprovetheirroleandperformanceintheRequest-Test-Reportcycle
establishcurrentpracticeandprepareGPsforimprovedknowledgeandpractice
provideopportunityforGPstobuildontheirimprovedknowledgeandchangestocommunicationsystemsinordertoimprovecompliancewithexistingguidelinesandtheuseofdiseaseregistersandrecallsystems.
These aims and objectives were achieved by this project.
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Outcomes
Detailedmappingofcurrentpracticeindetectionandmanagementofpre-diabetesthroughfocusgroups,GPclinicalauditactivityandretrospectivepathologyreports.Bestpracticewasestablishedthroughaliteraturereviewandconsultationwithdiabetesorganisationsandexpertsinthefield.Gapswerethenidentifiedandaneducationplandevelopedandimplemented.
KeyrecommendationsarisingfromtheoutcomesofthemappingofcurrentpracticeweredevelopedandsenttoallmajorpathologylaboratoriesoperatingintheFremantleDivisionboundariesinFebruary2005.
DevelopmentandimplementationofarangeofeducationopportunitiesforGPsandPracticeNurses(PNs)onthepreventionofdiabetes.
GPswerepreparedforimprovedknowledgeandpracticebycompletingPhase1oftheclinicalaudit,receivinganindividualandgroupreportoftheirresultsfromtheclinicalaudit,andreflectingontheircurrentpracticebycompletingareflectionandactionplan.
EducationopportunitiesforGPsincluded:o registerandrecalleducationo workshopso phase2oftheclinicalaudito receiptofregularretrospectivepathologyreportso bestpracticeguidelinesandpatientresources.
Development,distributionandevaluationofbestpracticeguidelinesonthedetectionandmanagementofpre-diabetesforgeneralpractice.
Development,implementationandrolloutnationallyofafivestageclinicalauditforGPsonthedetectionandmanagementofpre-diabetes.
Presentationofprojectresourcesatthe2004AustralianDiabetesSociety(ADS)–AustralianDiabetesEducatorsAssociation(ADEA)NationalConferenceinSydney.
“ThePracticalManagementofPre-diabetes–AGuideforGeneralPractice”wascompletedinmid-June2004with803copiesdistributedthroughoutAustraliaasof29April2005.
ApatientinformationleafletwasdevelopedinJuly2004with4,892copiesorderedbyGPs,PNsandDivisionsofGeneralPracticeby19April2005.
Samplecopiesofthepre-diabetesresources,alongwithanorderform,weresenttoallDivisionsofGeneralPracticeinAustraliainOctober2005,withordersformultiplecopiesreceivedfromninedivisions.
TheclinicalauditwasredesignedandsubmittedtotheRoyalAustralianCollegeofGeneralPractitioners(RACGP)foraccreditationtoberunnationally.
TheclinicalauditwasofferedtoallDivisionsofGeneralPracticeinAustraliainMarch2005with65divisionsorderingcopiesasof29April2005.
Findings
Thispilotprojectdemonstratedthesuccessfulimplementationofawhole-of-practiceapproachtoimprovingthedetectionandmanagementofpre-diabetesingeneralpractice.
ParticipantGPschangedtheirclinicalpracticeinrelationtomeasurementofweight,BodyMassIndex(BMI)andwaistcircumferenceinpatientsatriskofdiabetes.
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Over50%ofGPsstatedtheyhadchangedtheirpracticeasaresultofparticipatingintheclinicalaudit.
Datafromentryandexitquestionnairesshow67%ofGPshadaregisterandrecallsystemforpre-diabetesascomparedto42%priortotheclinicalaudit.
Morepracticeshaveaneffectiveregisterandrecallsysteminplaceforpatientswithimpairedfastingglucose(IFG)/impairedglucosetolerance(IGT)toensuretheyaretestedregularlyfortheonsetofType2diabetes.
Recommendations 1. AllDivisionprogramsshouldadoptawholeofpracticeapproachinall
projectsinordertoaddressallstakeholdersingeneralpracticeratherthanjustfocusingonthegeneralpractitioner.
2. OfferfutureclinicalauditsduringthefirstorsecondyearoftheRACGPQualityImprovement&ContinuingProfessionalDevelopmentProgram(QA&CPD)triennium.
3. GPswhoenrollintheQA&CPDshouldberequiredtocompletePhase1andPhase2oftheclinicalaudit,asthereissignificanteducationalvalueincompletingPhase2.
4. Ensurethereisaclearunderstandingwithprojectstakeholdersofthetimeframewhenputtinginafundingsubmissiontoensurethatcircumstancesdonotchangesignificantlybetweenprojectplanningandprojectimplementation.
5. Continuetoreviewcurrentliteratureonbestpracticeforthemanagementofpre-diabetestoensureresourcesremainuptodateandrelevant.
6. OffertheclinicalaudittoGPseverythreeyears.ThiswillensuretheGPNetworkhasacurrentandaccuratepictureofgapsinthemanagementofpre-diabetes.Asthetoolsarealreadydevelopedthiswouldnotbeatimeconsumingexercise.
7. Continuetoidentifymethodstoovercomethebarriersidentifiedbygeneralpracticeinthedetectionandmanagementofpre-diabetes.
8. Continuetopromotethe‘PracticalManagementofPre-diabetes–AGuideforGeneralPractice’togeneralpracticeasaresource.
9. JointGuidelinesfromtheAustralianDiabetesSociety–AustralianDiabetesEducatorsAssociationareduetobeformalisedshortly.Theseshouldbeincorporatedintothecurrentresourceasatearoutpage.
10. Offeravarietyofregulareducationandupskillingactivitiestogeneralpracticeonthedetectionandmanagementofdiabetes
11. OfferfundstoDivisionsofGeneralPracticeacrossAustraliatoimplementtheclinicalauditandassociatededucationalactivities.
12. Pathologylaboratoriesoffer,aspartoftheirservicetogeneralpractice,theregularprovisionofpracticeleveldataontestresultsofalltypes.
13. Alltrainingprovidedtopracticesondevelopingeffectiveregistersandrecallsystemsfordiabetesshouldalsoincludepre-diabetes.
14. GPNetworkshouldcontinuetoadvocateforandsupportpreventativehealthinitiativesthatutilisetheprofessionalexpertiseofthepracticenurse.
15. PracticevisitsshouldbeofferedtoallGPNetworkpracticesonanannualbasistooffersupportfortheirdiabetesandpre-diabetesregisterandrecallsystemstoensuretheyareuptodateandbeingmaintained.
16. Allpracticeshaveinplaceaprotocoltoupdateandmaintaintheirregisterandrecallsystems.GPNetworkstaffcanassistpracticestodevelopthis.
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17. GPscodepatientswithIFG/IGTprospectivelyastheyarediagnosedtoensuretheyareincludedintheregisterandrecallsystemsandpracticeshaveanaccuratepictureoftheirat-riskpatientpopulation.
18. Continuetopromotethepre-diabetesresourcesandeducationactivitiesdevelopedthroughthisprojecttogeneralpractice.
19. Runeducationeventseverytrienniumonthepreventionofdiabetes.
Key Project Learnings
Twenty-oneGPsenrolledtoparticipateintheclinicalaudit“ImprovingGPaccesstoanduseofretrospectiveandcurrentpathologydatatoincreasedetectionofpre-diabetes(IGTandIFG)ingeneralpractice”.SixteenGPscompleteddatacollectionforSteps1-4.EightGPsenrolledinStep5oftheclinicalauditandfivecompletedthedatacollection.Theattritionratewasduetoseveralreasonsincludingcompetingtimecommitments,involvementinotherDivisionalprojectsand2004beingthefinalyearoftheRACGPQA&CPDtriennium.
OneoftheaimsofthisprojectwastodevelopcommunicationsystemsbetweengeneralpracticesandpathologylaboratoriesthroughtriallingaformatforfeedbacktoGPs.Duetothetimedelaybetweenprojectplanningandprojectimplementation,GeneralPathologyLaboratories(GPL)hadalreadyputthisinitiativeintooperationanditwasnotincludedasaninterventioninthisproject.Theuseofretrospectivepathologyreportsprovidedbythepathologylaboratorytothegeneralpracticeastheinterventiontoimprovecommunicationsystemsbecamethefocusinstead.
Amultifacetedapproachtoimprovingthedetectionandmanagementofpre-diabetesprovedtobeaneffectivestrategythattargetedallthestakeholdersingeneralpractice.ThisapproachincludedthedevelopmentoflinkededucationandresourcesforGPs,PNsandpatients.
ThepathologylaboratoriesandinformationmanagementsystemsingeneralpracticewerealsotargetedtoensuretheinfrastructurewasinplacetosupportGPsandPNstoimprovethemanagementofpre-diabetes.Thisstrategyalsoensuredthatallcareprovidersandpatientswereprovidedwithconsistentinformation.
CombiningeducationaloutreachforGPs,PNsandpatients,auditandfeedback,alongwithprovisionofresourcesandinformationmanagementsupportwaseffectiveinpromotingbehaviourchangeamonghealthprofessionals.
InvolvingPNsinallaspectsofthisprojectwasasuccessfulstrategy.TheroleofthePNingeneralpracticeisrelativelynewandtheirrolesanddutiesarecontinuallyevolving.ByprovidingeducationforPNsandlinkingittoGPeducation,GPscouldunderstandandutilisethepotentialofthePNtoprovideeducation,distributeresourcesandassesslifestyleriskfactorsinpatients.
Thestrategyofprovidingcontinuingmedicaleducationlinkedtotheworkplace,plannedtomeetGPsneedsandbasedonself-assessmentandpeerreviewprovedtobeeffectiveinthisproject.ThebaselinedataprovidedbytheclinicalauditinformedthedevelopmentoftheeducationalactivitiesandresultedinparticipantGPstakingpartineducationdesignedtomeetneedsidentifiedthroughtheclinicalaudit.
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Thevaryingeducationalactivities,rangingfromclinicalaudittoeducationworkshops,wereeffectiveinaddressingthebroadeducationalneedsofGPs.Italsoallowedtheknowledgegainedfromthiseducationtoleadtosustainablechangesinpracticethroughtheincorporationofinformationmanagementstrategiesandprovisionofresourcesforpatients,GPsandPNs.
Undertakingarangeofactivitiesenabledadetailedpictureofcurrentpracticetobedeveloped.Thishelpedinthedevelopmentandimplementationofacomprehensiveeducationplanthataddressedallaspectsofgeneralpractice.Asaresult,allplannededucationalactivitieswerewellattendedandreceivedandresultedinrealchangesinpracticebyGPsandPNs.
Theinvolvementoflocalpathologylaboratoriesatbothasteeringcommitteeandprojectimplementationlevelenabledgeneralpracticeandpathologylaboratoriestofurthertheirknowledgeabouttheserviceseachprovides,andhowtoimprovethelinkagesbetweenthem.
Areas for Future Consideration
InvestigatetheareasPracticeNursescanassistwithinformationregardingpathologytestingandpatienteducation.
Quality Use of Pathology Services Education Program (2006)
Description AstructuredprogramforteachingdiagnosticpathologybypathologistsandscientificstaffwasdevelopedanddeliveredtoyearthreemedicalstudentsattheUniversityofSydney’sSchoolofRuralHealth(formallyDubboClinicalSchool)overafour-yearperiod(2003-2006).
Grant Recipient UniversityofSydney
Aims and Objectives
toachieveimprovementinthehealthandeconomicoutcomesoftheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequestersandprovidersofpathologyservices
toproduceagreaterunderstandingofpathologytestsbymedicalstudents toequipmedicalstudentswiththecapacitytoactmoreconfidentlyinclinical
situationsinwhichpathologyservicesmaynotbereadilyavailable toprovidemedicalstudentswithabetterunderstandingofthepathological
processofdiseaseandtherealisticroleofthepathologylaboratory. These aims and objectives were achieved by this project.
Outcomes
AprogramtoprovideastructuredprogramfortheteachingofdiagnosticpathologybypathologistsandscientistswasdevelopedforstudentsatTheSchoolofRuralHealth.
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Pathologyteachingwasincorporatedintotheyearthreemedicalstudents’academictimetabletomakeitanintegratedpartofmedicaltrainingatTheSchoolofRuralHealth.
Partofthecoursedemonstratedthatacliniciancanmakeanaccuratediagnosisinrural/remotepracticewithsimpleequipmentandbasicpointofcaretechnology.
Thestudentsspenteighthalfdayscoveringthemajordisciplinesofpathology,andwereinvolvedinautopsiesandformaltutorials.
Independentevaluationsofthecourseweresubmitted.
Findings
TheSchoolofRuralHealthnotedthevalueofteachingpathology,andstudentopinionwasinfavourofpathologyteaching.
Pathologydepartmentsatbothsitesacknowledgethebenefitsoftheprojectandindicatedthatteachingwouldcontinueintheshortterm.
Aindependentexternalreviewernotedthefollowingstrengthsoftheprogram:
o ithadastrongcorrelationwithclinicalpracticeo theinvolvementofabroadrangeofstakeholders(scientists,
technicians,pathologistsandphysicians)todelivertheprogramobjectives
o enthusiastic,engagingandcommittedstaffatbothcampuseso thegoodrelationshipbetweenthepathologylaboratoriesandThe
SchoolofRuralHealth,UniversityofSydneyo thecloselocationbetweenTheSchoolofRuralHealth,thehospitals
andthehospitalpathologylaboratorieso goodphysicalteachingfacilitieso positivefeedbackabouttheprogramfromthemedicalstudentso willingnessofstafftoimprovetheprogram.
Asecondindependentexternalreviewernoted:o theprogramhadthepotentialtoprovideamodelforteaching
laboratorymedicineinthesenioryearsofmedicalcourseso theinitialfundinghadbeenwell-utilisedtobuildanexcellentteaching
programwithgreatpotentialasamodeltoadvancethebetteruseofpathologyinhealthcare.
Recommendations 1. TheSchoolofRuralHealthwillconsideranothersubmissioninconsultation
withtheAustralianGovernmentDepartmentofHealthandAgeing.Independent external reviews recommended: 2. Developstrategiestoensurethatstudentscanparticipateinallaspectsofthe
programsuchasensuringthestudent’stimetablesarecompatiblewiththepathologysessionsorintroducingapathologyprize.
3. Ensuremoreconsistencyinthedeliveryoftheprogrambetweenthecampuses.
4. Greaterclarityforstudentsandsomestaffregardingthelearningobjectivesandoutcomesoftheprogramsuchasthelearningstandardsrequired.
5. Moredetailedplanningonhowthemedicalschoolwillmanagethedeliveryoftheprogramifpathologistnumbersarereducedfurther,includingpossibly
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developinglinksbetweentheprivatepathologyservicesandTheSchoolofRuralHealth.
6. DevelopmentofformalassessmentprocessestoalignwiththelearningobjectivesinvolvingtheUniversityofSydneyMedicalEducationUnit.
7. Moreaccesstostaffdevelopmentprogramstohelpwiththeprogramdevelopmentanddelivery.
8. TheUniversityofSydneyandtheAreaHealthServicemustprovidemoreacademicteachingstaffforthisteachingprogramtocontinueanddevelopsuccessfully.
9. Secure,long-termfundingarrangements,probablyinvolvingtheAustralianGovernmentDepartmentofHealthandAgeing,mustbenegotiatedtoensurecontinuationoftheteachingprogram.
10. Considernetworkingwithsimilarprogramsinothermedicalschools.11. Furthersupportofthisprogramisstronglyrecommended.
Key Project Learnings
ThetimeandresourcesspentbyacademicsandsupportstaffwasnotfactoredintotheagreementwiththeAustralianGovernmentDepartmentofHealthandAgeing.
TheSchoolofRuralHealthidentifiedalackofadministrativesupportandformalcoordinationbetweentheircampusesinOrangeandDubboandthepathologytutorsasasmallbarriertothesuccessfuldeliveryoftheprogramtostudents.Thisfactormustbeaddressedtomaketheprogramsustainable.
Casebook/skillslogbooksweredevelopedandsuppliedtostudentsatbothcampuses,however,sincetheircompletionwasnotarequirementoftheUniversity’smedicalcoursetherewaslimitedsuccesswithstudentsfillingthemout.Newassessmentmethodswillneedtobestandardisedanddevelopedacrossbothcampuses.
Areas for Future Consideration
Assesstheviabilityofre-establishingthisprograminruralmedicalschools.
Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008)
Description ThisprogramsoughttodevelopaprogramtoidentifythereasonsforincompleteorincorrectpathologyrequestformssubmittedbymedicalstaffinalargeteachinghospitalinSydney.Thiswasdoneusingaquestionnaire,focusgroupinterviewsandauditsofpathologyrequestforms.
Grant Recipient RoyalNorthShoreHospital
Aims
todeterminethetypeoferrorsthatcanoccurinthecompletionofpathologyrequestforms
todeterminethereasonsfortheseerrors todeterminetherelativeimportanceoftheseerrors
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todeterminetheimpactoftheseerrorsonlaboratorystaff. These aims were achieved by this project.
Outcomes
Onehundredandfourquestionnaireswerecompletedbyinterns,residentofficers,registrarsandconsultants(342weresentout).
Anauditof236randomlyselectedpathologyrequestformsoveraperiodofonemonthtodeterminethetypeoferrorsandomissionsandtheirfrequency.
Anadditional179requestformscompletedbyinternswerealsoaudited.Thisconsistedoftwoseparateauditsthreemonthsaparttodeterminetheeffectoftheworkenvironmentonthecompletionofrequestforms.
Anauditoftimespentseekinginformationfromclinicalstaffduetoincompleteorinadequaterequestforms.
Findings Staff Attitude Theclinicalstaffdidnotconsideritnecessarytocompleteapathology
requestform,particularlyclinicalandmedicationdetails,whichshowedamajorproblemwiththeattitudeoftheclinicalstafftowardsthepathologyrequestform.
Clinicalstaffdidnotunderstandtheimpactofincompleteorincorrectpathologyrequestformsonlaboratorystaffincludingtheextraworkrequiredbylaboratorystafftofindthemissinginformation.Therewasalsocorrespondingresentmentamongstlaboratorystaffwhichadverselyaffectedcommunicationbetweenthetwostaffgroups.
Time Issues Onereasonforincompletedocumentationonthepathologyrequestform
wastoomaysectionstobecompletedwhichtooktimetofillin. Theamountoftimewastedandthereforecosttothelaboratorybecauseof
errorsinrequestformsisconsiderable.OmissionofIDoftherequestorandrequestorcontactdetailsarethesectionsthatcausethemostwasteoftimeforcollectorsandlaboratorystaff.
Laboratorystaffspentaconsiderableamountoftimetofindthemissingorincorrectinformationonthepathologyrequestform.Thismeansthatanyimprovementinthecompletionrateandaccuracyofpathologyrequestformswillimprovelaboratoryproductivity.
Errors Theauditshowedsixsectionsonthepathologyrequestformaccountedfor
about80%oftheerrorsandcausedsignificantproblemsforlaboratorystaff.Thesewere:
1. clinicaldetails2. medicationdetails3. requestorcontactdetails4. IDoftherequestor5. IDofthecollector6. collectiondetails.
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Ofthesesections,clinicalandmedicationdetailswerethemostfrequentlyomittedwhichhaveasignificantimpactontheinterpretationandreportingoftheresult.
Education Internswereverygoodatcompletingpathologyrequestforms,withthe
exceptionofclinicalandmedicationdetails,atthestartoftheircareer.However,theirerrorrateincreasesovertimewhichindicatesthateducationandfeedbackareessentialtomaintaingoodclinicalpractice.
Medicalstaffhaveagoodunderstandingofthemedico-legalaspectsofthepathologyrequestform.
Educationshouldtargetafewkeyareasratherthancoverallsectionsoftherequestform.
Theworkenvironmentdoesnotencouragejuniormedicalstafftocorrectlycompletepathologyrequestforms.Theyaregivenlittlefeedbackabouttheirperformanceinthecompletionofrequestforms.
Recommendations 1. Developaneducationprogramthattargetsthemostimportanterrorsor
omissionsonrequestforms.2. Aneducationprogram,whichincludeslaboratorystaff,mustbegiventoall
medicalstaff.Theerrorrateinconsultantsissufficientlyhightowarrantprovidingfurthereducation.
3. Reviewthecontentandformatofpathologyrequestformsanddecidewhichsectionsdonotrequirecompletionbymedicalstaff.Removingnon-essentialsectionswillallowmoretimeforcompletionofessentialsections.
4. Reviewtheformatofthepathologyrequestformtofacilitatecompletionofthemostessentialsections.
5. Movetoelectronicrequestformswhichwillallowtheimplementationofmandatoryfields.
Follow on Initiatives and Projects
ABestPracticeinPathologyRequestingandReportingWorkshop(2009)onpage175wasconvenedbytheAustralianGovernmentDepartmentofHealthandAgeingtofurtherexplorerequestingissueswithkeystakeholders.
Areas for Future Consideration
Reviewtheformatandcontentofpathologyrequestforms. Investigateimplementinganeducationprogramwhichtargetsthemost
importanterrorsoromissionsonrequestforms.
Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009)
Description Thisprojectsoughttoundertakeaneedsassessmenttoinformthedevelopmentofatrainingprogramandseriesoftrainingmodulesfocusedonmaximisingtheuptakeofeducationandtraininginthequalityuseofpathologybygeneralpractice(GP)RegistrarsandInternationalMedicalGraduates(IMGs).Itadopted
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theviewthatimprovedvocationaltrainingintheappropriateuseofpathologywillassistinaddressingtheissuesfacedbyGPRegistrarsinmovingfromahospitalbasedtrainingsettingtocommunitybasedgeneralpractice,especiallysinceregistrarsindicatedthatitwaseasiertoseekadviceandfeedbackregardingpathologyuseinthegeneralpracticeenvironment.
Grant Recipient UniversityofAdelaide
Aim
toidentifythepathologytrainingneedsofGPRegistrarsandIMGstoinformthedevelopmentofatrainingmodule/sfocusedonmaximisingqualityuseofpathology
Objectives
toundertakeaneedsassessmenttoinformthedevelopmentofatrainingmodulefocusedonmaximisingtheuptakeofeducationandtraininginthequalityuseofpathologybyGPRegistrarsandIMGs
toinvestigatetheworkundertakentoassesstheeducationalneedsofGPRegistrarsandIMGsinrelationtopathologytesting
togaininsightintoGPRegistrars’andIMGs’knowledgeofpathologytesting,theirtrainingexperienceandtoidentifygapsintheirtrainingtoassistindesigningtheNeedsAssessmentSurveytobedisseminatedtoawidergroupofGPRegistrarsandIMGs
togaintheperspectiveofpathologyprovidersonthecurrenttrainingneedsforGPsandIMGs
togainanunderstandingofGPRegistrars’andIMGs’knowledgeofpathologytesting,theirpathologytrainingexperienceandtoidentifygapsintheirtraining.
The aim and all objectives were achieved by this project.
Outcomes
Aliteraturereviewwasconductedtoinformtheconductoffocusgroups,pathologyproviderinterviewsandthedevelopmentofaneedsassessmentsurvey.
AqualitativeanalysisviafocusgroupswithGPRegistrarsandIMGstogaininsightintotheirknowledgeofpathologytesting,theirpathologytrainingexperiencesandtoidentifygapsintheirtraining.
AqualitativeanalysisviainterviewswithpathologyproviderstogaintheirperspectiveonthecurrenttrainingneedsforGPRegistrarsandIMGs.
Informationfromthefocusgroupsandinterviewswasusedtodevelopaquestionnaire.
AquantitativeanalysisviaaNeedsAssessmentSurveydisseminatedtoabroadercohortofGPRegistrarsandIMGstogainanunderstandingoftheirknowledgeofpathologytesting,theirpathologytrainingexperiencesandtoidentifygapsintheirtraining.
Findings Literature Review
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ThisstudyconfirmedthereisalackofpathologytrainingbeingprovidedtoGPRegistrarsandIMGs.
TheliteraturereviewhighlightedalackoftrainingforGPRegistrarsandIMGsintheareaofpathologytesting.
Thereviewhighlightedanumberofareasrelatingtothequalityuseofpathologyingeneralpracticeincluding:
o EvidenceindicatesarelationshipbetweenGPs’characteristicsandpathologyutilisation.Forexample,femaleGPsandyoungerGPstendtoordermorelaboratorytests.
o Pathologyusageislinkedtoleveloftrainingandexperience.AstheconfidenceofGPRegistrarsandIMGsincreases,theirtestorderingbehavioursmayimprove.ForRegistrarsitwilldevelopwithknowledgeandexperience;forIMGsitwilldevelopastheygainabetterunderstandingoftheAustralianhealthcaresystem.Thisisalsorelatedtoconfidenceandknowledge.
o Additionally,knowledgeofclinicalguidelines,sizeofpracticeandutilisationofspecificallydesignedpathologyorderingformsimprovedqualityuseofpathology.
o PatientprofilecaninfluencepathologyorderingforGPs.Patientswithahigherlevelofeducationrequestedmorepathologytests.
o Anumberofinterventionswhichrangefromfeedback,educationandauditstoorderingprotocolshavebeenshowntoimprovepathologyordering.Themostsuccessfulapproachesutilisemultifacetedstrategies.
o ThereexistsalackofdesignatedpathologytrainingattheundergraduateandpostgraduatelevelsinAustraliaandparticularlyforGPRegistrarsandIMGs.
o Differentgroupshavedifferenttrainingneeds.Forexample,IMGsrequiretrainingintheAustralianhealthcaresystem,communicationskillsandclinicalmanagementwithintheAustraliansetting.Anytrainingmoduleneedstoensurethesedifferencesareaddressed,whileotherareaswillbesimilartotheneedsofGPsundergoingregistrartraining.
o AnationalsurveyonpathologyteachinginprevocationalandGPvocationaltrainingidentifiedtheneedforapathologyauditpackageforGPs.
Focus Groups Thefocusgroupparticipantsandinterviewsconfirmedtheexistenceofgaps
inthepathologytrainingbeingprovidedtoGPRegistrarsandIMGs. Mostpathologytrainingatundergraduatelevelwasreceivedthroughcase-
basedorconditioned-baseddiscussionsandproblem-basedlearning(PBL). Mosttrainingandexperienceatpostgraduatelevelwasgainedthrough
clinicalplacementsingeneralpracticeandthehospitalsetting. RuralGPRegistrarsindicatedtheywouldlikefurthertrainingoncollecting
andpreservingsamplesproperly. Thefocusgroupparticipantsidentifiedtheconditionswhichappearedto
causethemostdifficultiesinregardstotestorderingas:o rheumatologyo menopausalandinfertilityproblems
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o vagueillnessessuchastiredness. Thefocusgroupparticipantsidentifiedthetestsmostdifficulttointerpretas:
o rheumatologyresultso liverfunctiontests(LFTs)o lipidtestso hormoneso prostatespecificantigen(PSA)
Testresultsthatweremildlyelevatedandmoderatelyabnormalposedthemostproblems.
Thefocusgroupparticipantsidentifiedsupervisorsandcolleaguesasthepeopletheywouldmainlyapproachforassistancewithtestorderingandtestinterpretationdifficulties.Theyoftensoughtadvicefrompathologyproviders,butmostlyinregardstotestinterpretation.
Pathology Provider Interviews ThepathologyprovidershighlightedLFTs,fullbloodcounts,thyroidfunction
tests(TFTs)andreproductiveendocrinologyastheteststheyreceivethemostcallsinregardstoassistancewithtestinterpretation.
ThepathologyprovidersbelievedthefollowingtestswereoverusedbyGPs:o TFTso PSAo glycatedhaemoglobin(HbA1c)o lipidso tumourmarkerso vitaminB12o folatetests.
Situationstheymightreceiveacallaboutatestresultincluded:o atestresultislateo atestresultforapatientwhohasbeenseenbyaGPorspecialist
outsidethepracticeo atestresultforaGPwhosepracticeisnotcomputerised.
TheyreceivedthemostenquiriesfromGPsinruralandremoteareas,IMGsandolderGPs.
TheyreceivedmorecallsfromGPstohelpinterpretatestresultthanforadviceonthemostappropriatetesttoorder.
Theneedtohavesufficientinformationontherequestingform,includinggoodcontactdetailsfortheGP,washighlightedasveryimportant.
Allintervieweesbelievedtherearegapsinthecurrentmedicaltrainingregardingpathologyincludingpracticalaspectssuchas:
o howspecimensarecollectedo thetimingofspecimencollectiono thedifferencebetweenthefirstpassedspecimenofurineandamid-
streamurineo bestpracticetocultureawound.
PathologyprovidersindentifiedthefollowingareasforinclusioninpathologytrainingforGPs:
o practicalsessionsonspecimencollectionandtypesofspecimenso moreeducationaboutcommontestsandtheiruseinscreeningo theimportanceofprovidingappropriateandsufficientclinicalnotes
onrequestforms
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o specificinformationabouttests/conditionsthatareapplicabletotheareainwhichtheGPisworking.
Youngerdoctorsandfemaledoctorstendedtoordermorepathologyasagroup.
Needs Assessment Survey Pathologytrainingdiminishesasparticipantsmovethroughtheirlevelsof
medicaltraining. IMGsreportedlesstestinterpretationproblems.Asthiscohortwereolder
andgraduatedearlierthantheGPRegistrars,thiswasthoughttobeassociatedwiththeiryearsofexperience.
Bothgroupsrequestedfurthertraining,particularlyforreproductivehormonesincludingtheinfertility/pregnancytestsaswellashepatitisserologytests,andmoreinformationaboutnewtestsandadvancesinpathologytesting.
Thecasescenarioalsoidentifiedseveralteststhatmaybeinappropriatelyusedincludingferritin,creatinekinase,erythrocyte sedimentationrate(ESR)andc-reactiveprotein(CRP)tests.Itisunclearifthisisduetoalackofunderstandingontheuseofthesetestsoraresultofpanelordering.
Theparticipantsidentifiedseveralconditions/symptomswhichcausedthemthemostproblemsinregardstopathologytesting.Participantshadthegreatestdifficultywithtestorderingandtestinterpretationsforconditions/symptomsthatarevagueand/orwheretherewerenoguidelinesordecisionsupportsystemsavailable.Incontrast,theleastdifficultywasreportedforconditionssuchasdiabetes,lipidsandurinarytractinfectionswhereclearmanagementguidelinesareavailable.
Presentationsofweakness/tirednessandmenopausalsymptoms/complaintswerereportedasconditionscausingthemostproblems.
Theformatinwhichparticipantswouldliketoreceivefurthertrainingincludedcasestudies,shortseminarsorconferencesandon-linelearningresources,withcasestudiesbeingmostfavouredbyIMGs.
Recommendations 1. Atrainingmodule/stoincludeinformationontheapplicationofthetests
identifiedascausingthemostdifficulties.2. Atrainingmodule/stoincludestrategiesandavailableevidence-based
resourcestomanageconditions/symptomswherenoguidelinescurrentlyexist.ThemodulealsoneedstoincludeinformationtohelpraiseawarenessaboutthedifferencesbetweenpathologytestinginthehospitalandGPsetting.Thiscouldincludeuntilising‘awaitandsee’approach,communicatingeffectivelywithpatientsandadvocatingtheimportanceoftakingadetailedhistory.
3. Thetrainingmodule/sbeprovidedinmultipleformatsanddesignedtosuittheeducationmaterialbeingprovided.
4. GPSupervisorsadvisedofthepathologytrainingneedsforGPRegistrarsandIMGS,andprovidethemwiththeeducationandresourcestoassisttheminthisknowledgetransfer.
5. Establishaworkingparty,includingaGPSupervisorandapathologyprovider,todevelopthetrainingmodule/sforimplementationthroughGPtrainingproviders.Itisimportantthatthemodule/sbecontinuallyupdated
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toreflectthebestevidence-basedresourcesavailable,andthattheparticipant’spathologytrainingneedsareperiodicallyevaluated.
6. Areas/topicssuggestedbythisproject’sfocusgroupandintervieweesforfurtherpathologytraininginclude:
a. practicalsessionsoncollectingandpreservingsamplesb. commontestsandtheiruseinscreeningc. whatiscoveredundertheMedicareBenefitsSchedule(MBS)d. howtofindpathologyinformationallinonespote. informationonspecifictests/conditionsthatareapplicabletothearea
inwhichtheGPisworking.7. Pathologyproviderswouldlikeasessiononprovidingappropriateand
sufficientclinicalnotesonrequestforms.8. Supervisorscanplayakeyroleinprovidingfurtherpathologytraining.
Follow on Initiatives and Projects
ProjectoutcomeswerepromotedattheBestPracticeinPathologyRequestingandReportingWorkshoponpage175.
Areas for Future Consideration
Possibledevelopmentofatrainingprogram/modulestobeprovidedtoGPRegistrarsandIMGs,andtheneedforatrainingmodule/s.
Developfactsheetscoveringthearea’shighlightedinrecommendationno.6above.
Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010)
Description Thisprojectsoughttotestthehypothesisthat‘withholding’ofantimicrobialsensitivityreportinginconjunctionwithaselectiveevidence-basedinformativecommentwillresultin: lessongoingantibioticusageinelderlyfemalepatients fewerantibioticsideeffects improvedpatientcare improvedoutcomes significantcostsavings.
Grant Recipients FlindersMedicalCentreandSouthAustraliaPathology
Aim
totestthehypothesisthatthe‘unjustified’antimicrobialtreatmentofasymptomaticbacteriuriainelderlyfemalescouldbereducedbyutilisingamodifiedmicrobiologyreportinwhichfullmicrobialspeciationwasnotperformed,antimicrobialsensitivitydatawasnotreportedandashorteducationalcommentregardingthelikely(orlackof)clinicalsignificanceoftheresultwasincludedinthepathologyreport.
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This aim was achieved by this project.
Outcomes
Urinesamplesreceivedintheroutinediagnosticmicrobiologylaboratoryfromfemalesaged70yrsandoverwithdetectedbacteriuria(>105cfu/ml)wereconsideredforrandomisationtoeither:
o fullreportingofisolateatthespecieslevelwithan‘appropriate’choiceoforalandintravenousantibioticsreported.Asaminimum,sensitivitytoampicillan,cephazolin,timethoprimandgentamicinwasreported,withadditionalantibioticsiffirst-linedrugresistancewaspresentOR
o generalreportingofthemicrobiologyresultwithoutprovisionofanymicrobialsensitivitydata,butinclusionofthefollowingcomment:‘Asymptomatic bacteriuria in elderly women does not usually require antibiotic treatment. Sensitivities are available upon request.’
Womenwereexcludedfromthetrialif:o therewasanindicationfromclinicalnotestosuggesttheirbacteriuria
wassymptomaticorthatantimicrobialsmightbeindicatedo theywerereceivingantimicrobialsforanotherclinicalindication
whichhadactivityagainsttheurinaryisolate.
Findings
Ratesofantimicrobialprescribingforurinarytractinfection(UTI)were202of272(74%)inthereportedgroup,and205of293(70%)inthesensitivitiesmaskedgroup.
Thesubsequentanalysiswasperformedin470subjectsafterexclusionof95subjectsforreasonsnotavailabletothelaboratoryatthetimeofrandomisation.
TheinterventionofmaskingantimicrobialsensitivitiesandprovidingeducationalcommenthadasmalleffectonantimicrobialuseforUTI.
Sensitivitieswereonlyrequestedin45%ofcasesofthegroupreceivingmaskedreportswhowereprescribedantibiotics.Thisfindingindicatedthepracticeofnotconfirmingantibioticsensitivitiesdespiteprescribingantibioticswascommon.
Therewasconsiderablevariationinthedurationofantimicrobialuse. Antimicrobialswerewidelyused‘unnecessarily’inbothgroupswhich
highlightstheimportanceoftargetededucationalprograms. Alimitationofthestudywastheconsiderablenumberofsubjectswhere
antimicrobialswereinitiatedempirically,eitherforpresumptivesymptomaticUTI(withnoindicationofthisonthepathologyrequestform)oronthebasisofimmediatedipsticktestscollectedonadmission.
Therewasnoapparentadverseclinicaleffectassociatedwithmaskingantimicrobialsensitivityresults.
Themeanlengthofstayforthemaskedversusreportedgroupwere13.3daysand14.2daysrespectively.
Follow-upurinespecimenswerecollectedwithsimilarfrequencyinbothgroups.
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Educationalinterventionsarebeneficialbutrequiresignificantresourcestoinstigate,mayloseeffectovertimeandmaynotpreventantimicrobialprescribingoncea‘positive’urineresultisobtained.
Antimicrobialuseisassociatedwithadditionalcosts,toxicityandtheemergenceofresistance.
Recommendations 1. Strategiesforreducingunnecessaryprescribingforasymptomatic
bacteriuriacouldbedirectedatreducingthenumberofspecimensinitiallysentfromasymptomaticpatients,orprovidingeducationalinformationregardingthesignificanceoftheresult.
2. Providingonlylimitedinformationonthelaboratoryreport,andaddingabriefeducationalcommentinanattemptto‘downplay’thepotentialsignificanceofthepositiveurineculture,couldbeutilisedatessentiallynocostandbeeasilysustainedwithongoingresources.Incorporatingadditionalcomponents,suchascomprehensiveeducationalprograms,willproducethebestoutcomes.
3. Educationalprogramsshouldbetargetedtospecificgroupstoempowerthemtodevelopconfidenceinwithholdingantibioticsforasymptomaticpatients.
4. Educationalprogramsshouldalsotargetnursingandmedicalstafftoeducatethemonnotobtainingurineforanalysisunlessthepatientissymptomatic.
5. AutomaticstopordersafterthreeorfivedaysofantibioticuseforUTIcouldbeinitiatedinahospitalsetting.
6. Additionalcommentssuchas‘Recommended duration of antimicrobial therapy for symptomatic, uncomplicated UTI is 5 days for β-lactams and 3 days for trimethoprim/quinolones’couldbealsobeaddedasasupplementtolaboratoryreports.
Areas for Future Consideration
Produceafactsheetonantibioticuseandbacteriuriaforalllevelsofmedicalstaff,includingnurses,toempowerthemtodevelopconfidenceinwithholdingantibioticsforasymptomaticpatients.
Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010)
Description Thisprojectsoughttoidentifywhethercomputerisedpathologyorderentry(CPOE)systemswithvaryinglevelsofelectronicdecisionsupport(EDS)canenhancetheefficiencyofpathologyservicesandleadtomoreeffectiveandrationalpathologyorderingandimprovedpatientoutcomes.WhileresearchhasshownthatCPOEhasthepotentialtosupportmoreefficientpathologyservices,itistheEDScomponentwhichholdsthepromiseformakingsubstantialimprovementsindeliveringmorerationalpathologyorderingandimprovementsinpatientsoutcomes.
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AmajorlimitingfactorinderivingbenefitfromCPOEwithEDSisthelackofresearchevidenceregardingwhichlevelofEDSisusefulandwhichspecificEDSfeatureswillimprovepathologypracticeandpatientoutcomes.ThisprojecttargetedthislargeknowledgegapbyundertakingadetailedanalysisofthreelevelsofEDS.
Grant Recipient UniversityofSydney
Aims and Objectives
toidentifyhowcomputerisedpathologyordersystemswithvaryinglevelsofelectronicdecisionsupportcanenhancetheefficiencyofpathologyservicesandleadtomoreeffectiveandrationalpathologyorderingwhichimprovespatientoutcomes
toundertakeamulti-sitestudywhichwill:a. undertakeaglobalassessmentoftheimpactofCPOEonpathology
practicemeasuringabroadrangeofeffectiveness(e.g.lengthofstay)andefficiency(e.g.turnaroundtime)indicators
b. measuretheimpactofdifferentlevelsofEDS(basic,intermediateandadvanced)onqualityofinformationprovidedtolaboratories,rationalpathologyorderingandpatientoutcomes.
These aims and objectives appeared to be partially achieved by this project as the report did not articulate the level of EDS for each outcome/finding, nor did it articulate the 39 measures across the spectrum of the pathology test processes (see outcomes).
Outcomes
Thereportednotedthereviewidentified39measuresclassifiedinto10impactareasacrossthespectrumofpathologytestprocesses(ordering,processingandreporting).Theseincludedmeasuresof:
o turnaroundtime(TAT)o testvolumeso redundanttestso costso guidelinecomplianceo workpracticeso communicationo patientmanagemento lengthofstayo adverseevents/safety.
Thisprojectresultedin13peer-reviewedpapersincludinganumberinhighimpactinternationaljournalsandconferenceproceedings.
Thisprojectalsoresultedin19presentationsincludinginvitedandkeynotepresentationsatmajornationalandinternationalfora.
Theproject’sresearchersalsoreceivedaninvitationbytheAmericanCollegeofPathologiststocontributeachapteronelectronicmedicalrecordstotheCollegetextbook,andaninvitationtooutlinetheirworkinthefoundingissueoftheJournal of Pathology Informatics.
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Findings
Turnaroundtime,testvolumes,redundanttests(testsreorderedwithinaninappropriatetimeframeprovidingnoadditionalinformation)andlengthofstay(thenumberofdaysapatientremainsinhospitalfromadmissiontodischarge)canprovidevaluableinformationtomonitortheimplementationofCPOEanddrivebenefitsrealisation.
Thereisvalueinusingastandardisedrecordlinkagetechniquetogenerateaqualitydatasetwithenrichedinformation.Analysesappliedtotheseenricheddatasetscanprovidevaluableinformationtohealthsystemplanners,cliniciansandpathologymanagersforuseinmanagingandevaluatingnewCPOEsystems.
ThevariousmeasuresofCPOEperformanceandimpactprovideaframeworktoassess:
a. efficiency–testvolumes,communicationb. effectiveness–testcosts,redundanttestrates,TAT,workpracticesc. quality–patientsafety,compliancewithguidelines,patient
management,lengthofstay,patientsafety. ThestudyfoundtheCPOEsystemproducedsustainedandcontinuing
improvementsinlaboratoryefficiencyoveratwo-yearperiod. AregressionanalysisdemonstratedthatTATwasasignificantfactor
contributingtopatient’slengthofstayintheemergencydepartment.ThisprovidedevidencethatreducingTATsviatheintroductionofaCPOEmayproduceimprovementsinthesepatients’outcomesintermsofreducedlengthsofstay.
Theratesofmissedtestresultswerelowerthanthosefromstudieswherepaperorderingandreportingsystemswereused.ThissuggeststheavailabilityofCPOEsystemsmayreducetheriskoftheseevents.Electronicresultdelivery,withelectronicendorsementtoallowdocumentationoffollow-uptestresults,mayprovideadditionalefficiencybenefitsandfurtherreducetheriskoftestresultswhicharenotfollowedup.
TherewasapositiveimpactofusingtheCPOEfornotifyingthehaematologylaboratoryaboutpatientsonheparinorwarfarintreatmentwhenorderingactivatedPartialThromboplastinTime(aPTT)orProthrombin(PT)/InternationalNormalisedRatio(INR).ThemedianTATalsodecreasedfrom28to21minutesforaPTTandfrom34to23minutesforPT/INR.DecreaseswerealsoshownforTATinnormaltestresults(30to22minutes)andabnormalrestresults(33to23minutes).
Recommendations 1. Associationsbetweenincreasedmortalityratesandtheintroductionofa
computerisedproviderorderentrysystemshouldbeinvestigatedcarefullytoascertainanylikelyassociation.
2. ConductresearchintothechangeinlengthsofstayinemergencydepartmentsfollowingtheintroductionofCPOE.
Follow on Initiatives and Projects
Continueddevelopmentasstage2intheprojectTheImpactoftheImplementationofElectronicOrderingofPathologyRequestingandtheQualityandEffectivenessofHospitalPathologyServices–BuildingaRobustEvidenceBaseandBenefitsFrameworkforSuccessfule-HealthDiffusions
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The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current)
Description Thisprojectisdevelopingperformanceindicatorstoevaluatethequalityandeffectivenessofelectronictestorderinginarangeofhospitalsinmetropolitan,regionalandruralsettings.Itisbeingconductedinthreestages,andtheevaluationwillexaminethequalityofpathologytestorders,laboratoryturnaroundtimes,re-testingandadd-ontesting.
Grant Recipient UniversityofNewSouthWales(UNSW)
Aim
toprovideresearchevidence,employingkeyindicatorsofpathologyorderingefficiencyandeffectiveness,oftheimpactofelectronictestorderingontheutilisationanddeliveryofhospitalpathologyservicesacrossfivehospitalsindifferentdemographicsettings(majormetropolitan,regional,country)withintheSouthEasternSydney(PrinceofWales,RoyalHospitalforWomanandStGeorge)andIllawarraShoalhaven(Wollongong,Shoalhaven)LocalHealthNetworks.
Objectives
providekeycomparative(acrosshospitals)andlongitudinal(overtime)evidenceabouttheeffectofelectronicorderingsystems
produceasuiteofbenefitsrealisationindicatorsthatcanbeusedtomonitorwhatworks(orwhatdoesn’twork),where,andinwhatcircumstances
utiliseasetofperformanceindicatorstoevaluatetheimpactofelectronicorderingonthequalityuseofpathologyacrossthefollowingareas:
o thelegibilityandcompletenessoflaboratorytestordersandtheimpactonCentralSpecimenReceptionworkprocesses(qualityoftestorders)
o thetimelinessofthepathologylaboratoryprocess(laboratoryturnaroundtimes)
o thevolumeandmixoftestsorderedexaminedbysuchfactorsasDiagnosisRelatedGroups,wardlocationordepartment,andadjustedforclinicalactivitywhereappropriate
o theimpactonre-testandadd-ontestrates.This project is current and the aim and objectives are in the process of being achieved.
Outcomes ByearlyDecember2011thefollowingactivitieshadbeenachieved: ethicsapprovalgranted
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extractionoffirstdataforanalysisconcentratedon:o LaboratoryInformationSystem(turnaroundtimes,testorder
volumes,re-testratesandadd-onrates)o CentralSpecimenReception
analysisofCentralSpecimenReceptionworkprocesseshavebeenundertakentoinvestigatetheeffectofelectronicmedicalrecordandincidentreportingonthelaboratorytestprocessingprocedures,suchasward/laboratorycommunicationandefficiency.
Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010)
Description Thisprojectsoughttodevelopasoftwareplatformforuseinpathologycasestudiesforjuniordoctors.TheiNvestigatewebsiteis:http://investigate.med.unsw.edu.au/
Grant Recipient UniversityofNewSouthWales(UNSW)
Aim
todevelopafullyfunctioningsoftwareplatformtouseasabaseforanon-lineeducationalprogramforjuniordoctors.
This aim was achieved by this project.
Outcomes
AnalphaversionofthesoftwareprogramwasdemonstratedtotheQualityUseofPathologyCommittee(QUPC)on24February2010.Sincethattimefirst-passtestingofallcomponentsofthesoftwarecommencedwithseniorundergraduatemedicalstudentsrecruitedtoevaluatetwobetaversions.Thisledtomajorchangestoselectedareasoftheprogram.
OnecycleoffeedbackfromacademicstaffinpathologyattheUNSWandfromDrWendyPryorattheRoyalCollegeofPathologistsofAustralasia(RCPA)identifiedissuessimilartothosenotedbystudents,aswellassuggestionsforenhancingthecontent.
FurtherfeedbackafterthesecondmajorrevisionofthebetaversionwasdeployedfromProfessorFredDee,theoriginatoroftheLabCAPSconcept,whichhighlightedfurtherchangesrequiredtotheinterfacefortheUserrole.
TheCaseBuilderinterfacewastestedwhichledtoiterativechangestocertaincapabilities.
ManualcodingforeachitemsolvedtheproblemsassociatedwithlinkingMedicareBenefitsSchedule(MBS)datatoindividualtestitems.
Theprocessofenteringresultswhenbuildingacasewassimplifiedbycreatingasetof‘default’normalvaluesforallofthetestsavailablewithiniNvestigate.
Acompletesystemofself-registrationofnewusershasbeenimplemented.
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Agraphicdesignerwasemployedtocreatealogo/bannerfortheiNvestigatewebsite.
Providingaconsistentuserinteractionforaggregatedtestitemsprovedtobeasignificantchallenge,mostlyduetotheseaggregatedtestsnotbeingconsistentlyrepresentedintheRCPAManual.Thiswassolvedbyanextensible,easy-to-usesystemavailabletouserswithAdministratorrightstoaggregatetestsasneeded.Thiscateredforexistinggroupingsandallowedthecreationofnewgroupeditemsasrequired.
AllotherRCPAManualitemshavebeenincludedinthefullydevelopediNvestigatewebsite.
Topromoteinterestinandtheuseofinvestigate,juniormedicalofficers(JMOs)wereengagedwithdirectlyandthedevelopershavesoughttoembediNvestigateintoJMOtraining.
Variouselementswhichenhancetheeducationvalueand/orfunctionalitynotenvisagedaspartoftheoriginaldesignhavebeenincorporatedintothesoftwarepackageincluding:
o arunningtallyofthecostoftestsorderedbasedonindicativedatafromtheMBS
o aneffectiveandvisuallypleasinguserinterfaceo arangeofvaluableadministrationtoolsincludinganovelandsimple
testaggregationtool.
Recommendations 1. TakestepstomakeiNvestigatearecommendedresourcedisseminated
nationallyviatheAustralianCurriculumFrameworkforJuniorDoctorsProject.
2. FundinghasbeenrequestedfromtheQualityUseofPathologyProgram(QUPP)tocreatealibraryof20-25educationallyrichcasescenarioswithinputfromaspecialistpathologistemployedontheproject.
Key Project Learnings
AlloftheseniorstudentswhotestedthewebsitemadeitcleartheywouldnotreadahelpfileorclickthroughahelpsystemtolearnhowtouseiNvestigate.Theysuggestedanyrelevanthelpshouldbeprovidedonthepageitself.Thisledtotheoriginalplantoprovideacompletehyperlinkedhelpsystemtobeabandoned,andtheuserinterfacewasre-designedsothatcontext-relevanthelpwasprovidedatthetopofeachpage.
FeedbackaboutproblemswiththedatasetandomissionsidentifiedwereprovidedtoProfessorBrettDelahunt,ChairoftheRCPAManualEditorialCommittee.Infuturethisisanticipatedtoleadtoco-operativeinteractionandimprovementoftheRCPAdataset,whichwillinturnleadtotheimprovementoftestavailabilitywithiniNvestigate.
ItismoreappropriatetoaskJMOstoundertaketestingwhenalibraryofcaseshasbeendeveloped.
Follow on Initiatives and Projects
iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase2(2011).
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iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011)
Description ThisprojectfollowsonfromPhase1andsoughttodevelop20to25authenticcasestudiesspanningallpost-graduationyearone(PGY1)relevantareasofclinicalpracticeandrelatedinvestigations.TheiNvestigatewebsiteis:http://investigate.med.unsw.edu.au/
Grant Recipient UniversityofNewSouthWales(UNSW)
Aims and Objectives
todevelop20to25authenticcasestudiesforiNvestigate toenhancethesoftwarevia:
o reviewandoptimisationofthe‘virtualuniverse’ofinvestigationsavailableforordering
o programmingofanimproveduserinterface.These aims and objectives were achieved by this project.
Outcomes
Twelvecaseshavebeendevelopedandafurther10areinvariousstagesofdevelopment.
Allcasesstudies,oncetheyarefullydeveloped,willundergoprogressiveexternalreviewandimprovementasappropriate.
Over30additionalinvestigationshavebeenaddedwhileatleastanother30investigationsnowhavesynonymsorabbreviationsincludedinthenamelabeltoimprovefulltextsearching.
Theinterfacewasupgradedtostreamlinetheuser’sinteractionwiththewebsite.
Thereisenhancedsearchingfortests. Thewebsitehasbeencontinuouslyavailablesinceitwaslaunchedwitha
demonstrationcaseon6June2010.RakeshKKumarfromtheDepartmentofPathologyatUNSW,andtheMedicineComputingSupportUnitatUNSW,sharetheresponsibilityforhostingthewebsiteandensuringitsavailability.
TherehasbeenasystematicefforttopubliciseiNvestigate,althoughthemostsignificantissuesinthelongertermistheimpactofexternalfactorsonthecapacityofthoseinvolvedwithiNvestigatetopromoteitsdisseminationandusebythetargetaudience.
ThelackoffundingfortheAustralianCurriculumFrameworkforJuniorDoctorsProjectwillinevitablyadverselyaffectthevisibilityofiNvestigate.
Otherapproachestodisseminatethisresourcearebeingexplored.Forexample,theRoyalCollegeofPathologistsofAustralasia(RCPA)haveprovidedalinkviaitsEducationPortaltotheiNvestigatewebsite.
RakeshKKumar,fromtheDepartmentofPathology,UNSW,incollaborationwithProfessorGaryVelanofUNSW,hascreatedaclonedsitecalled‘eDiagnostic’withaccesstothiswebsiterestrictedtostudentsenrolledintheMedicineprogramatUNSW.
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Finding
Thecriticalissuefortake-upispersuadingthePGY1graduatestomakethetimetouseiNvestigate,andnotthequalityoftheresourceitself.
Recommendations 1. ResearchavenuesforiNvestigatetobedeployedforothertargetaudiences
withthedevelopmentofsuitablecases.Forexample,createacloneofiNvestigatewithcasesformedialstudentssuchaseDiagnostic.
2. IdentifyfurtherrelevanttargetaudiencessuchastheTheRoyalAustralasianCollegeofPhysicians(RACP)ortheRoyalAustralasianCollegeofGeneralPractitioners(RACGP),anddevelopnewcases.
Key Project Learnings
ChallengesassociatedwithreachingiNvestigate’sintendedtargetaudiencewerenottechnicalissues,butissuesrelatedtodisseminationandtake-up.OnepotentialbarriercontributingtothisissueisthatwhatiNvestigate offersmaynotbewhatthetargetaudiencewants.Toaddressthis,feedbackfromPGY1graduatesduringthedevelopmentalphasewasessentialbutdifficulttoobtain,mostlybecausethesegraduatesaresobusytheyhaveinsufficienttimetobeinvolvedinalloftheeducationalactivitiesavailabletothem.Considerableeffortshavebeenmadetorecruitgraduatestoprovidespecificcommentaryandfeedbackalthoughtherehavebeenfewactiveparticipantssoitwasnotpossibletogatheruserquestionnairedata.Thefewwhoofferedcommentarywereverycomplementary.
Alesserissuehasbeenrecruitingspecialistreviewersforthecasesandfindingtheyarenotascomputer-savvyastheirPGY1juniorcolleagues.
OtherissuesrelatetoinvestigationsmissingfromtheRCPAManualwhichthereforehavenoassociateddataiftheyareincluded.ThiswasresolvedbytakingadvantageofthehighlyflexibleadministratorinterfacedevelopedforiNvestigate.
Follow on Initiatives and Projects
iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations(Current).
Areas for Future Consideration
IdentifyfurtherpotentialusersforiNvestigate.
iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current)
Description ThisprojectisStagethreeoftheiNvestigateinitiativeandisrebuildingtheplatform,includingdatabasestructureanduserinterface,toallowmultipleaudienceandinterfaceextensibility,andtoalsoallowtheiNvestigatewebsiteto‘golive’forongoinggeneralpractitioner(GP)instruction.TheiNvestigatewebsiteis:http://investigate.med.unsw.edu.au/.
Grant Recipient UniversityofNewSouthWales(UNSW)
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Aims
todevelopafullyfunctioningsoftwareplatformtouseasabaseforanon-lineeducationalprogramforjuniordoctors
toallowmultiplecasesetsonthewebsitetobedevelopedinthisinstanceforthespecifictargetaudienceofgeneralpractitioners.
This project is current and these aims are in the process of being achieved.
Outcomes
Stageonewasapilotstudywhichdevelopedthesoftwareplatformandatestcasescenario.
Stagetworesultedinthedevelopmentof20-25casescenarioswithappropriateinstructionalvalueandallowedthewebsiteto‘golive’forprevocationalmedicaltrainees.
Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011)
Description Thisprojectinvolvedexploring,documentingandreviewingtheeffortsmadeinAustralia’spublichospitalstobettermanagethedemandforandappropriateuseofpathologytestinginthecareofpatients.Thiswasexploredinthreeparts:
1. Understandingthedifferentapproachestakentoconsideringappropriateandinappropriatepathologyorderinginthehospitalsetting.
2. Creatinga‘snapshot’ofcurrentandplannedstrategiesinpublicpathologyservicesacrossAustralia.
3. ExaminingtheavailableevidenceinrelationtothetypesofinterventionsanddemandmanagementstrategiesimplementedinAustraliaandoverseas,andtheirimpactonclinicians’testrequestingpatterns.
Thisprojectalsosoughttoredresssomeofthedeficienciesindefinitions,approachesusedandassociatedmeasuresofappropriateversusinappropriatetestordering.Amatrixforappropriatepathologytestorderingwasalsodevelopedwhichcombinesthedifferentpurposesofpathologytestingwiththebroadclinicalindicatorsforuse.
Grant Recipient NationalCoalitionofPublicPathology(NCOPP)
Aims and Objectives
todocumentandreviewtheknowledgeandexperienceinAustralianpublichospitalsinordertobettermanagethedemandforanduseofpathologytestinginpatientcare
toconsiderthelessonslearnt toestablishfuturedirectionsforachievingsustainablechange. These aims and objectives were achieved by this project.
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Outcomes
Asurveyofcurrentandplannedpracticesfoundthatmostpublicpathologyservices(75%)aredoingsomethingtosecureimprovementsinappropriatepathologyorderinganduseinthepublichospitalstheyserve,withtheseeffortsmostlyledbypathology.
Afundamentaldifficultytheprojectgrappledwithconcernsthelackofaconsistentdefinitionof‘appropriate’versus‘inappropriate’pathologytestordering.Toresolvethisproblemtheprojectdevelopedamatrixencapsulatingauniformnationaldefinitionthatcouldbeappliedtotheassessmentofwhetherarequestforanyoreverypathologytestwasappropriate.Thematrixrecognisesthatinthehospitalsystemandtheentirehealthcaresystemtherearemanydifferentcircumstanceswhenorderingofpathologyinvestigationsiswarranted.Thematrixthereforecombinesthedifferentpurposesofpathologytestingwithbroadclinicalindicationsforuse:
o ifnoneoftheboxesinthematrixcanbeticked,thetestshouldberegardedasinappropriate
o similarly,ifaccordingtothematrixthereisanindicationforatesttobedoneanditisnotordered,thiswouldsuggestinappropriateorderingofpathologyasaresultoffailuretoorderanindicatedtest.
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[alt=“Thefollowingtableisamatrix.TheYaxisshowsthePurposeofPathologyTestingandtheXaxisshowstheClinicalIndicationsforUse.”]AppropriatePathologyTestOrderingMatrix
Purpose of Pathology Testing
Clinical Indications for Use
Indicated for Acute/ Immediate Patient Care
Indicated as part of a Clinical Pathway/ Standard Care for patients with that condition
Indicated for Public Health Objective
Indicated to assist good Patient Flow
For Diagnosis
For Treatment
For Monitoring – disease or therapy
For Assessment of Possible Adverse Event or Side-effect
For Exclusion of a Possible Diagnosis
Required to Assess or Manage a Comorbidity
(separate to main diagnosis)
Screening*
©NCOPP2011*NOTE:Thiscoverstheuseoftestsforpurposesof‘diseasescreening’.Formalpopulationbasedscreeningprogramsarerecognisedindicatorsforpathologytests,butgenerallytheyarenotundertakenaspartofusualpatientmanagementinthepublichospitalsetting.However,patientsinpublichospitalsmayhavepathologytestsaspartofacomprehensiveassessmentoffactorspotentiallycontributingtoaproblemoraspartofahealthcheckstrategy.
Thisreview’sproposedapproachtoareaswherepublicpathologyservices
mightbestcontributeandaddvaluetobuildingtheevidencebaseandextendingtheefforttoimprovepathologyorderinganduseinAustralia’spublichospitalsectorisguidedbyfiveprinciples:
1. Actingonmajorgapswherepathologyservicescanaddvalue.2. Promotingacollaborativeeffortamongpublicpathologyservices
throughoutAustraliainordertoovercomecurrentfragmentation.3. Targetingeffortstoaddressareaswheretheyarelikelytohavean
impact.4. Identifyingfactorslikelytocontributetosustainability.5. Supportingthedevelopmentofaframeworkthatisusefulthroughout
thecountryandinavarietyofpublichospitalsettings.
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Findings
Numerousreasonshavebeenputforwardtoexplaintheincreaseduseandcostsofpathologyalthoughfewhavebeenexaminedwithanyrigour.Theyinclude:
o advancesintechnologyenablingmultipleteststobeperformedonthesamespecimenreliablyandinexpensively,andmorerapidturnaroundofservices
o theavailabilityofnewtestsgivingmorefromwhichtochooseo extendingtheclinicalapplicationsoftestingacrossthediagnosis,
monitoring,screeningandprognosisspectrumo changesinclinicalpracticeo over-relianceontestorderingtodealwithuncertaintyo ‘patientpower’–specificallytheincreaseinpatients’knowledge
throughinternetaccess,andgreaterpatientexpectationsoftheclinicalencounterandthehealthsystemgenerally
o theincreaseddemandforcareasaresultofanageingpopulationandgrowingnumbersofpeoplewithchronicdisease
o theteachingofpathology(laboratorymedicine)o theabsenceofpricesignalsatthepointofrequesto perceptionsofpotentialmedico-legalliabilityiftestsarenot
performedo ignoranceofthediagnosticsignificanceoftestsandtheirsensitivity,
specificityandpredictivevalueo fearofbeingcriticisedbyseniorcliniciansforfailingtoorderatesto research,habitandmerecuriosity.
Appropriatepathologytestrequestingiscentraltocost-effective,qualitypatientcareandhealthcaregenerally.
Therearemanystrategiesthatcanchangethefrequencyofpathologyorderingwhichfallintofivebroadcategories:1. Education,auditandfeedbackwhichconstituteaneffectivedemand
managementstrategy,althoughtheeffectgraduallydeclinesduringtheperiodaftertheintervention.
2. Rulesandagreementsaimedatrestrictingtestrequestswhereminimumre-testintervalsaresuccessfulineffectingandmaintainingareductioninunnecessaryrepeattestrequestsbyclinicians,asevidencedbythesustainabilityoftheinterventions.Traffic-lightsystemshavebeeneffectiveintargetingthetestrequestbehaviourofjuniordoctorsinemergencydepartmentsthroughimprovingthequalityofrequestingandreducingunnecessarytesting,includingrepeattesting.Theeffecthasbeensustained–betweenfourand11years–inthethreeStatesandTerritorieswherethissystemhasbeenimplemented.Whenclinicalguidelinesareimplemented,seniorcliniciansarelikelytorequestfewertestsiftheyhaveamoredirectinvolvementinplanningclinicalpathways,andintheearlystagesofthepatient’smanagement.
3. Re-designingtherequestformtoprovideguidancetorequestershasbeeneffectiveinreducingtheuseofpathologytests,regardlessofthepurpose.Overallthisappearstobeaneffectivemechanismforsupportinggoodclinicalpractice,especiallyamonginexperiencedjuniordoctors.Therearestillquestionsovertheimpactofpricesignalssuchasdisplayingtestcostsontherequestformontestrequesting.
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4. Computerisedphysicianorderentry(CPOE)systemshavebeeneffectiveinbringingreal-timeevidence-baseddecisionsupporttorequestingphysiciansandfacilitatingeffortstomanagethedemandforpathology.Tobesuccessful,CPOEtechnologyneedstobedevelopedtoalevelofutilityandefficiencythatisacceptabletousers,withstakeholdersacceptingtheinvestmentrequiredandtheneedtoadoptcoordinatedimplementationplans.Thedesignanddeploymentofsuchtoolsarestillintheirinfancy.
5. Reimbursementandfundingmodelsdesignedtomanagethedemandforpathologytestinghavenotbeenexaminedtoanygreatdegree.Onlyonestudywasfoundtoinformthispracticewherehospitallaboratorybudgetsweretransferredtorequesters,however,theobserveddecreaseintestorderingreturnedtoitsformerpatternafterafewyears.
Alloftheabovestrategieshavethecapacitytodeliverasuccessfuloutcome,althoughthereisnoconsensusonamodel(ormodels)forbroaderadoptioninthelongterm,andsustainabilityremainsproblematic.
Successinachievingsustainedimprovementinappropriateorderinganduseofpathologyinpublichospitalsappearstobeassociatedwiththeinterplayofanumberofcriticalfactors:
o targetingmultiplebehaviouralfactorso basingmodelsonprovenandrobustbehaviouralscienceprinciples
usingamultifacetedapproacho clinicalengagementandownershipataseniorlevelo clinical‘champions’orleadclinicianstopromotetheapproacho strategiesthataresimpleandeasilyintegratedintoeverydaypracticeo adaptingstrategiestomeetlocalneedsandcircumstances.
Theimportanceoftheculturalbehaviouraldeterminantsofpathologyrequestingisoftenunderestimated,anditisthesefactorsthatmostprobablyholdthekeytolong-termsuccess.
Virtuallyallinterventionsusuallyhaveanimmediateandsignificantimpactonorderingpatternswhichisoftenshort-lived.Thismightpartlyreflectthelimitedtimeframeofmostpublishedstudies(interventionsgenerallylastingfromseveralmonthstoayearortwo)andlackoffollow-uponlonger-termsustainability.
Australianpublichospitalsvaryintermsofsize,locationandtypesofservicesprovidedandarecomplexorganisations.Everyinterventionwouldrequireamultifacetedapproachwithdifferentelementsorareasofemphasisfordifferenthospitalsettings.
EffortstosecureimprovementsinappropriatepathologyorderinganduseinAustralianpublichospitalstendtobeadhocandfragmented.Whereinterventionshavebeensuccessfulinchangingpathologyorderingpatternsinjurisdictionsandinstitutionsthereislimitedevidenceofmovestoimplementtheinterventionsmorewidely.
Theprimarygapsidentifiedbythisreviewrelatetothefollowing:o lackofasingleorconsistentdefinitionof‘appropriate’versus
‘inappropriate’pathologyorderingo lackofconsistentmeasuresanddatacollectiontodeterminebaseline
levelsofpathologyorderingandtoassesstheimpactofinterventionsimplemented
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o lackofdatatoguidetheselectionofwhichareastotarget–particularlyacrossthediverserangeofpublichospitalsettingsinAustralia.
Recommendations 1. Developastandardnationaldefinitionof‘appropriate’pathologytest
ordering.2. Allfutureresearchandauditsshouldusethematrixtoreviewandassess
pathologytestorderingandtoevaluateinterventions.Itmayalsobeausefuleducationaltoolinaninterventionstrategyornationalguidelines.
3. DevelopstandarddatasetsonpathologyuseinAustralia’spublichospitalsfordatacollectionandbenchmarkingpurposeswithinitialeffortsfocusedonassessingthetop10to15diagnosisrelatedgroupsforpublichospitalsnationally,andthetop10to15pathologytestsusedinpublichospitals.
4. Monitorandparticipateindevelopingelectronichealthrecordsystemsandcomputerisedphysicianorderentrysystems.
5. Identifywhichchangesinthefrequencyofpathologyorderingwillminimisewastewithoutimpactingonpatients’healthcareoutcomesoraccessinAustralia’spublichospitals.
Key Project Learning
Itwaschallengingtoassembleevidencefromavarietyofsourcesandprovideaclearevidencebaseintermsofwhatisknownandunknownandtheassociatedlimitations.Studiesvaryintheirlevelofrigourandqualityandusedifferentmethodologiesandapproachestoreviewingoutcomes.Insomecasestheoutcomeswereunclear.Thisnecessitatedthedevelopmentofausefulgroupingofinterventionsandanassessmentframeworkthatdrewtogetherandexaminedtheevidenceavailableforsimilarinterventionsandallowedconclusionstobemade.
Areas for Future Consideration
Developastandardnationaldefinitionof‘appropriate’pathologytestordering.
Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current)
Description Thethreeorganisationsinvolvedinthisprojectareundertakingprojectworktowardsmoreeffectiveandconsumer-friendlypathologyreporting.
Grant Recipients UniversityofMelbourne;DianellaCommunityHealth;RoyalCollegeofPathologistsofAustralasia(RCPA)
Aims
toidentifyacoresetofkeyvisualcommunicationtechniquesforreportingpathologytestresultsbothtorequestingpractitionersandconsumers(includingconsumerswithlimitedliteracy)
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toprepareandtestseveralformatsdesignedtomaximisecommunicationwiththespecifiedtargetgroups(e.g.treatingclinicians,consumersfromculturallyandlinguisticallydiversebackgrounds,consumerswithlowliteracylevels)totestwhichformatswillbestengagehealthconsumersintheirowncare
todevelopaGPpracticepilottotrialthenewreportingformatunderclinicalconditions.
This project is current and these aims are in the process of being achieved.
Outcomes
Thedraftreportingformatshavebeendevelopedusingeye-trackingexperimentsandtestedwithconsumerfocusgroups.
Itisexpectedtherewillbeopportunitieswithinstageonetocarryoutsomepre-testingofthedrafttemplatewithgeneralpractitioner(GP)focusgroups.
PathologyprovidersandGPsarenowbeingrecruitedforthepilotthatwillformaproposedstagetwoofthisproject,althoughnodecisionhasyetbeenmadetoproceedtothisstage.
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Workforce Capacity and Competence Therelative‘invisibility’ofthepathologyworkforcehashadanumberofflow-oneffectsonitscapacityandcompetence.Pathologyisnota‘highprofile’choiceofspecialtyformedicalgraduates,whileotherfactorssuchasanageinganddecliningspecialistworkforceandunclearcareerpathwaysforscientistshavecontributedtowhatisrecognisedasapathologyworkforcecrisis.ThissituationisnotuniquetoAustraliawithworkforceissuesregardedasathreattotheglobalpathologysectorandthereforetothedeliveryofqualitypathologyservices.TheQualityUseofPathologyProgram(QUPP)hasenabledtheexplorationoftheseissuesthroughsixprojects(Table7).Detailedanalysesofworkforceissueshavebeenidentifiedaccompaniedbyalonglistofrecommendationstoachieveasustainablepathologyworkforceforthefuture.Areasforfutureconsiderationmayinclude: Investigatebetterdatacapturingmethodsfortheassessingpathology
workforce. Devisestrategiestoincreasetheprofileofpathology. Continuetoaddresspathologyworkforceissues. Continuetomonitortheworkloadforpathologists. Investigatestrategiestopromotepathologyasanappealingcareerchoice. Investigatestrategiestoprovideincreasedaccesstopathologytopeoplein
ruralandregionalareas. InvestigateavenuestopromoteandutilisethePathologyAssociations
Council’ssetofcompetencystandardsusingtheeightpathwaysidentifiedinthereportCareerStructuresandPathwaysfortheScientificWorkforceinMedicalPathologyLaboratoriesonpage153.
ItisalsoimportanttonotethatsincethePathologyFundingAgreementwasimplementedon1July2011,muchoftheworkaddressingworkforceissueshasbeentakenoverbytheWorkforceAdvisoryCommittee(WAC)whichiscomprisedofrepresentativesfromtheAustralianGovernmentDepartmentofHealthandAgeing(DoHA),RoyalCollegeofPathologistsofAustralasia(RCPA),NationalCoalitionofPublicPathology(NCOPP),AustralianAssociationofPathologyPractices(AAPP),CatholicHealthAustralia,HealthWorkforceAustralia(HWA),PathologyAssociationsCouncil(PAC)andtheDepartmentofIndustry,Innovation,Science,ResearchandTertiaryEducation. Project Name Grant Recipient/s Page
No. 1 PathWay(2005) RoyalCollegeofPathologists
ofAustralasia(RCPA)136
2 TheAustralianPathologyWorkforceCrisis(2008)
MichaelLeggandAssociates 137
3 ReviewofPathologySpecialistDevelopmentPathways(2010)
RCPA 143
4 ImpactofWorkloadofAnatomicalPathologistsonQualityandSafety(2011)
RCPA 147
5 SurveyofthePathologyWorkforce(2011) URBIS 150
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6 CareerStructuresandPathwaysfortheScientificWorkforceinMedicalPathologyLaboratories(2011)
HumanCapitalAlliance(HCA) 153
Table7:ReportssummarisedforWorkforceCapacityandCompetence
PathWay (2005) Description TheRoyalCollegeofPathologistsofAustralasia(RCPA)identifiedaneedtostrengthenthepositionofthepathologyprofessioninboththemedicalandgeneralcommunitiesandconsequentlydevelopedastrategycalled“PathWay”.Thisincludedaquarterlylifestyleformatprintmagazine,Internetsite,print/electronicmaterialandmediaplacementaimedatenhancingthepathologyprofession’sstanding,perceivedrelevanceandcredibility.PathWayalsointegratedarangeofRCPAinformationproductsandcommunicationinitiatives,suchastheRCPAManual,CommonSensePathologyseriesandworkforceinitiatives,intoasustainedandcohesivecampaign.TheRCPArequestedandwasgrantedseedmoneyfromtheQualityUseofPathologyProgram(QUPP)toassistinfundingstage1ofthisproject.Grant Recipient RCPAAim enhancethepathologyprofession’sstanding,perceivedrelevanceand
credibility. Objectives topromotepathologyasavocationalchoiceamongnear/recentmedical
graduates topromoteevidence-basedpathologyorderingbymedicalpractitioners
(generalpractitioners[GPs]andrecentgraduates) topromotejointdecisionmakingwithconsumersinpathologyordering topromoteappropriatepathologyorderinghabitsamongnear/recent
medicalgraduates todevelopacampaignthatcanbesustainedwithoutgovernmentfunds. This aim and many of the objectives appeared to have been achieved although they were difficult to measure. Outcomes Stage1,2004–anintegrated12monthcampaignwhichfocusedonthe
productionofaquarterlylifestylemagazine(PathWay),Internetsite,print/electronicmaterialandmediaplacement.PathWayintegratedarangeofcurrentRCPAinformationproductsandcommunicationinitiatives,suchastheRCPAManual,CommonSensePathologyseriesandworkforceinitiatives,intoasustainedandcohesivecampaign.
Stage2,2005–developtargetsbasedontheobjectivesandachievementsofStage1.
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Stage2,2006onwards–assesstheachievementsandongoingviabilityofthecampaign.
PathWay wasdistributedtoallmedicalstudentsinAustraliaandNewZealand,andprovidedtojuniormedicalstaffinhospitalsinAustralia.
TherewaspositivefeedbackfrommedicalstudentsinAustraliaandNewZealand,andfromjuniormedicalstaffinhospitalsinAustralia,aboutthevalueofthemagazineinraisingawarenessofpathologyasacareerchoice.ThisissuewasdiscussedattheRCPA’sTraineeAdvisoryCommittee,whoreportedaconsiderablenumberofjuniormedicalstaffapproachingthemaboutacareerinpathologyfollowingneweditionsofPathWay.
Medicalstudentsandrecentgraduatesalsoprovidedpositivefeedbackinrelationtothecontentofthearticles,particularlyeducatingthemabouthowapathologistcanbeusedinadvisingonappropriateusageofpathologytestingandtheinterpretationofresults.
AnevaluationformsentoutwiththethirdeditionofPathWayprovidedpositivefeedbackandsupportfortheusefulnessofthemagazineineducatingGPsandrecentgraduatesonappropriatepathologyordering.
ThePathWaymagazineswereavailableinpathologycollectioncentresanddoctors’rooms.TheRCPAalsosoldavaluablenumberofsubscriptions.
ThearticlesinPathWaywerealsoavailableonthePathWaywebsiteathttp://www.rcpa.edu.au/pathway.
Finding ThePathWayprojectwasdeemedsuccessful,withPathWaymagazinea
particularlyusefultoolforpromotingpathologyandpathologiststothemedicalandgeneralcommunity.
Recommendation 1. PublishPathWayonanongoingbasis.Key Project Learning ThesaleofadvertisingspaceinPathWaywasdifficult,althoughtheRCPAhad
soldsufficientatthetimeoftheirreportforcontinuedproduction.Follow on Initiatives and Projects TheRCPAinitiatedanonlineversionofPathWay,titledePathWay,in2011.
The Australian Pathology Workforce Crisis (2008) Description Thisreportrepresentedthefirstnationaloverviewoftheissuesfacingthecomprehensivepathologyworkforce.Itsetsoutthescopeandstructureforthepathologyindustryworkforce,anddrawstogetherasummaryofthekeyissues,gapsandopportunitiesforfurtherworkassuggestedbypathologystakeholders.Grant Recipient MichaelLegg&Associates
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Aim toassisttheAustralianGovernmentDepartmentofHealthandAgeing
(DoHA)toprepareabackgrounddiscussionpaperwhichsetsoutthescopeandstructureofthepathologyindustryworkforce,anddrawstogetherasummaryofthekeyissues,gapsandopportunitiesforfurtherworktobeundertakenonthisissue.
This aim was achieved by this project. Outcomes Aseriesofconsultationswereundertakenincludingmeetingsincitiesinfour
States/Territories(Canberra,Sydney,MelbourneandBrisbane) Relevantreportsandsubmissionswereidentifiedandreviewed,and
submissionswereinvitedfromrelevantorganisations. TheProductivityCommissionReportonAustralia’shealthworkforce
identifiedthefollowingsystemicproblems:o fragmentedrolesandresponsibilitieswithhealthworkforcepolicy
‘compartmentalised’byprofessions,evenincircumstanceswhereanintegrated‘cross-profession’approachisclearlycalledfor
o inadequateco-ordinationmechanisms,inflexibleandinconsistentregulationwithalackofcollaborativepolicyeffortstoimproveco-ordinationacrossthevariouspartsofthesystem
o inflexibleandinconsistentregulationthatissubjecttoconsiderableinfluencefromtheprofessionalgroupsconcerned,andwidelyperceivedasinhibitingchangestoscopesofpracticeandthedevelopmentofnewcompetenciesthatcouldmeetchanginghealthcareneeds
o perversefundingandpaymentincentivesthatmayresultinpatientsseekingtreatmentfromadoctor,when(unsubsidised)treatmentfromanotherhealthprofessionalmaybemoreappropriate
o limitedincentivesformedicalpractitionerstodelegatelesscomplexserviceprovisiontoothersuitablyskilledbutmorecost-effectivehealthprofessionals
o entrenchedworkforcebehavioursthatareheavilyinfluencedby‘customandpractice.’
Findings Pathology Workforce Thereisarealproblemwithworkforceshortagesinpathology,andthe
availableprojectionsinferafurtherandsignificantimpactonservicequalityandtimelinessifurgentactionisnottaken.
Thecriticalshortagesarebestdocumentedforspecialistpathologists,andthereisgoodevidenceofacriticalshortageofscientists.
Thoseworkinginpathologybelievethatco-ordinationatanationallevelisrequired,asthesituationcannotwaitfora‘comprehensiveindustry-wide’solution.
Theactualvolumesplitbetweenpublicandprivatepathologyisnotknown,buthasbeenestimatedat60%privateand40%public.
Theaveragepathologyserviceepisodeinvolvesaroundonehourofworkedtimefromacomplexworkforceteamusingadiverserangeofskills.
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Thepathologyworkforceteamconsistsof:o specialistpathologistso medicalscientistso healthinformaticianso technicalofficersormedicaltechnicianso laboratoryassistantso collectorsandnurseso pathologycourierso clericalstaffandotherdirectoryinvolvedintestingo managementandsupportservices.
Thepathologyworkforceisestimatedatbetween30,000and50,000whichismorethan5%ofthetotalhealthworkforce.Atleast70%ofthepathologyworkforceisfemale.
Approximately50%ofSeniorScientistsareaged50orover,while20%ofPathologistsactivelypracticinginAustraliaareaged60orover.
Education and Training Onlypathologistshavearegistrationscheme. Educationprogramsrelevanttothepathologyworkforceareofferedby
universities,institutesoftechnology,TAFEcolleges,throughaccreditededucationcoursesconductedbypathologyorganisationsandthroughon-the-jobtraining.
Inadditiontoeducationinstitutions,16otherorganisationshavearoleinrepresentingandeducatingmembersofthepathologyworkforce.Thesecanbedividedintospecialistcolleges,scientificsocietiesandassociations,andindustryassociations.
Technicalofficersandmedicaltechnicianshavethegreatestvariationinthetrainingoffered,jobtitleandworkplaceexpectations.
Theneedsofthepathologysectorarenotcurrentlyrecognisedinthelargerhealthworkforcereviewactivities.
TheissuesrelatingtothepathologyworkforcehavealsobeenexperiencedbyothercountriessuchasNewZealand,theUSandCanada.
Australia’scomprehensivequalityandaccreditationsystemhasbufferedtheindustryfromincidentshappeningincountriessuchasCanada,andmanycountrieshaveobservedanddrawnonthesystemforlaboratoryaccreditationthatwasestablishedcooperativelyinAustralia.
Thestrongestofthedriversleadingtoworkforceshortageisdemography,andparticularlytheimpactofthe‘babyboomer’birth-ratebulgereachingretirementage.Whenthisiscombinedwithincreasedlifeexpectancythereisadoubleimpactforhealthcare;areducedsupplyofworkersandanincreasingdemandforservices.Theimplicationsofthissituationaremoreacutelyfeltinpathologybecausetheyarecompoundedbyothersector-specificissues.
Impacts and Demands on the Pathology Sector Theimpactoftechnologyonthepathologysectorisrelatedmoretodoing
‘newthings’ratherthandoing‘existingthings’faster. Therehashistoricallybeenanaverageincreaseinthevolumeoftestingof
around8%perannumwithoutamatchingriseinfundingwhichhasresultedina25-year‘efficiency’dividend.Thesituationisoftenexacerbatedbytheintroductionofnewtestsintocommonclinicalpracticebeforethesometimeslengthyprocessoffundinghasbeendetermined.
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Thedemandforpathologyisexpectedtoriseandisbeingdrivenbyfactorsincluding:
o increaseddiseaseprevalenceandcomplexitywithanageingpopulation
o increasedcancerprevalencewithincreasedlongevityo increasedemphasisonevidence-basedmedicinethatrequires
pathologyfordecisionmakingo increaseduseofpathologytestingforeligibilityforsubsidiseddrug
therapyandmonitoringo increasedgenetics(epigeneticandmolecularpathology)testingfor
pre-emptiveandpersonalisedmedicineo increasedconsumerexpectationthattestingispartofdiagnosisand
treatment. Thereisawidelyheldperceptionthatpathologyhaddeclinedinitsprestige
andcapacitytowinfundingagainstothermedicaldisciplineswhere“partisanmutualadjustment”isthenormintheresource-limitedenvironmentofhealthcare.Reasonsofferedforthisinclude:
o thelimitedactualcontactbetweenpathologistsandtheirpatientso areductioninclinicalemphasisonthescienceofmedicine,including
significantreductioninpathologycontentinmedicaltraining,withaconsequentunderestimationofthevalueofthecontributionmadebypathologytesting
o theerroneousperceptionbytheusersofpathologyandtheirpatientsthatpathologyisamachine-baseddisciplinewithlittlehumaninvolvementorexpertiserequired
o lackofpromotionofthevalueofpathologybythepathologyprofessionthemselves
o competitionwithintheindustryandthehighservicelevelsofferedbypathologypracticestorequestersandconsumers
o the“commoditisation”ofpathology,particularlyinthehospitalenvironment,whereithasbeensometimesgroupedanddealtwithinthesamewayassupportservicessuchaslaundryandcatering.
Theissuesspecifictopathologybutcommontoallpathologyworkforcegroupsinclude:
o alackofunderstandingandprofileofwhatpathologyisanditsvalueandsoalowerstandinginthecommunityandhealthcaresector
o theoptionofincreasingsupplybytheuseofoverseas-trainedpathologistsandscientistsishamperedbyaworld-wideshortageofwelltrainedpersonnel,especiallyinthesubspecialtieswithgreatestneedsuchastoxicology
o thereisanargumentthatlaboratoriesarenotbeingusedoptimallybyrequestersandthatfewermoreappropriaterequestswouldresult–however,thisisbalancedagainsttheevidencethatifprotocolsforcommondiseasessuchasdiabeteswerebeingadheredto,manymorepathologytestswouldbeorderedsuchasdoublethenumberofglycatedhaemoglobin(HbA1c)testsfordiabetics.
o theopportunitytofurtherremodeltheworkforceisimpairedbysomeoftheexistingworkpractices,awardstructuresandregulations.
Issues Specific to Medical Scientists o difficultyattractingnewrecruitsofappropriatequality
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o difficultyintrainingstaffo difficultyinre-entrytotheworkforce.
Issues Specific to Pathologists o toofewtraineepathologistsduetotoofewfundedtraineepositionso reducedexposuretopathologyinmedicaltrainingandtheassociated
lossofrolemodelsisreducingtheattractionoftheprofessionandthecalibreoftrainees
o thecurrentrateofadvanceofknowledgeisdifficulttokeeppacewith,especiallywhendemandsonserviceprovisionarehigh
o highworkloadso professionalisolationofpathologistsworkinginregionallaboratorieso decliningtraineesasgeneralpathologistso dual-trainedpathologistsspendingmostoftheirtimeinclinical
practiceo specificshortagesinsub-specialties.
Recommendations 1. ThepathologyworkforceisnottrackedbytheAustralianInstituteofHealth
andWelfare(AIHW)asforotherareasofhealthcareintheirbiennialreportsonAustralia’shealth,butitsfutureinclusionwouldimprovemonitoringoptions.
2. Acomprehensiveandregularlyupdateddatasetisrequiredtomanagethepathologyworkforceeffectivelyonanongoingbasis.Thisshouldincludenumbers,ages,sex,geographicaldistribution,educationallevels,employmentlevelsandotheressentialinformation.Strategiestodothismightinvolve:
a. fullworkforceandworkloadauditb. inclusionofpathology-relatedworkforcedataintheAustralian
InstituteofHealthandWelfare’s(AIHW)twoyearlyreportsc. increasetheprofileofpathologyinthenationalhealth-workforce
reviewactivities.3. TheCouncilofAustralianGovernments(COAG)responsetotheProductivity
CommissionReportincludedthefollowingrecommendations,manyofwhicharealreadyunderconsiderationand/orinplace:
a. reducehealthworkforceshortagesthroughsignificantinvestments,includingadditionalmedicalschoolandhighereducationnursingplacesandcapitalfundingformedicalschoolsandnurses’clinicaltraining.Theincreaseinmedicalschoolplaceswouldresultinanexpansioninthenumberofmedicalschoolplacesbondedtoareasofworkforceshortage
b. promoteworkforcemobilityandconsistencybetweenjurisdictionsbycreatingnationalregistrationandaccreditationschemesforhealthprofessions
c. providegreaterhealthserviceaccessforrural,remoteandindigenouscommunitiesbyintroducinganewMedicareitemforpracticenursesandregisteredAboriginalhealthworkerstoprovideongoingsupportforpatientswithchronicdisease
d. helpmedicalspecialisttraineesbuildappropriateskillsandexperiencebyprovidinganewsystemoftrainingrotationsthroughanexpandedrangeofsettingsbeyondtraditionalpublicteaching
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hospitals,includingregional,ruralandambulatorysettings,privatesectorhospitalsandpracticesandcommunitysettings
e. createanationalhealthworkforcetaskforcetoundertakeworkforceprojectsandadvisegovernmentsonworkforceinnovationsandreforms.
4. Thereisaclearneedforbetterinformationaboutthepathologyworkforceandbettermatchingoftrainingtotheworkplace.
5. Addresstheimageofpathologyby:a. continuingandacceleratingtheworkdonebytheRoyalCollegeof
PathologistsofAustralasia(RCPA)b. lobbyingforagreatershareofmedicalcoursetimec. engagingpathologyconsultativecommitteemembersandtheir
suppliersinanindustry-wideprogramd. coordinatingactivitiesthroughthePathologyAssociationsCommittee
toincreasetheimpactandmaximisethe‘bangforbuck’.Pathologists 6. Increasetheopportunitiesforeducationandtrainingandrecruitmentfor
medicalscientistsandtechniciansandpathologists(alistofpossibleapproachesareincludedinthereport).
7. Retaintheexistingworkforceforlonger(alistofpossibleapproachesareincludedinthereport).
8. Attractre-entryofthosewhohaveexited(alistofpossibleapproachesareincludedinthereport).
9. Providesubstitutionfromthoseoutsidethesectorbytrainingotherspecialistsinspecificsub-specialtyandsuper-specialtyareasofpathology(e.g.ophthalmicsurgeonsinhistopathologyoftheeye)andthensupportingthemthroughexistinglaboratories.
Other strategies 10. Redistributetheexistingworkforcegeographicallyandbydiscipline.11. Improvetheproductivityoftheworkforcethroughimprovedworkdesign,
newtechnologyandfurtherconsolidation.12. Reducethedemandforpathologyservicesbyimprovingthequalityof
ordering,orrationingthroughtheuseofmorerulesinthePathologyServicesTable.
13. Thenextstepsmayinclude:a. invitingcommentfromthoseconsulted,inparticularfromtheRCPA,
scientificsocieties,industrygroupsandeducationproviders,abouttherangeofstrategiesproposedinthisreportandtheirrelativepriority
b. engagingwiththeAustralianHealthMinisters’AdvisoryCouncilanditsrelevantcommittees(includingtheNationalHealthWorkforceTaskforceGroup)
c. engagingwithotherjurisdictionaldepartmentsthathavearoleinpathologyworkforceplanningsuchasAttorneysGeneralwhohavearoleinforensicpathology
d. establishinganationalsteeringgroupandagreeontheactionstobetakenbyprioritisingthesuggestionsprovidedhere,andanythatmaybepromptedbyreviewofthereport,byassessingthemagainstcriteriaofimportance,‘doability’,cost,impactandtimelinessinordertodraftastrategicplanforaction
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e. actingontheoutcomewithamulti-prongedapproach.Follow on Initiatives and Projects ReviewofPathologySpecialistDevelopmentPathwaysonpage143 ImpactofWorkloadofAnatomicalPathologistsonQualityandSafetyon
page147 SurveyofthePathologyWorkforceonpage150 CareerStructuresandPathwaysfortheScientificWorkforceinMedical
PathologyLaboratoriesonpage153 Theprofileofpathologyworkforceandassociatedissueswasraisedand
negotiatedsuccessfullyforinclusioninthePathologyFundingAgreement.Areas for Future Consideration Investigatebetterdatacapturingmethodsforthepathologyworkforce. Devisestrategiestoincreasetheprofileofpathology. Continuetoaddresspathologyworkforceissues.
Review of Pathology Specialist Development Pathways (2010) Description Thisprojectexaminedoptionstoachievemaximumefficiencyandeffectivenessofthepolicyandproceduresforpreparingnewspecialistpathologistsworkforceentrants.Thiswasinresponsetothecurrentandlong-standingworkforceshortageofpathologistsinAustraliawherestrategiestopromotetheuptakeofpathologyasacareercanbeconsideredinthreebroadareasofneed:
1. toenhancethevisibilityofpathologistsaskeymembersofhealthcareteamsandprovidersofvitalinputthatinfluencesaveryhighproportionofclinicaldecisions
2. toinvestigateandaddresspossiblebarrierstoundertakingpathologytraining,andtoactivelypromotepathologyasacareertomedicalstudentsandjuniordoctors
3. formoreflexibletrainingoptionsavailableinanextendedrangeofsettingswhicharesupportedandevaluatedtoensuretherequiredstandardsaremaintained.
Grant Recipient RoyalCollegeofPathologistsofAustralasia(RCPA)Aims toexamineoptionsforachievingmaximumefficiencyandeffectivenessofthe
policyandproceduresforpreparingnewspecialistpathologyworkforceentrants
todevelopstrategiestopromotetheuptakeofpathologyasacareer todevelopastrategicapproachtothesupplyofspecialistsforidentified
areasofsub-disciplineshortages(e.g.paediatric,neuropathologyandgeneralpathology)
togiveconsiderationtofutureplanningfortheprovisionofqualitypathologyservicesindifficult-to-servicelocations,includingregionalcentres.
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Objectives stage1involvedthepreparationofareviewofnationalandinternational
pathwaysforpathologyspecialisttrainingwhereinformationonarangeofstrategieswascollatedandpresentedforconsideration
stage2requiredtheexaminationofstrategiesindentifiedinStage1intermsofbestpractice,theirrelevanceandopportunitiesfortheirpossibleadoptionintheAustralianpathologycontext
stage3involvedareviewofthecurrentRCPAoptions,policy,proceduresandtraining/developmentsupportcapacityofitsFellows,withaviewtomaximisingandstreamliningopportunitiesforentrytothepathologistworkforceatanadequatelytrainedstandard
toreviewassessmentprocessesforoverseasqualifiedpathologistswhoneedfurthertrainingandassessmentpriortobeingabletoworkinAustraliaunsupervised
toreviewstrategiesforthedevelopmentofeducationalresources,particularlythosethataredeliverableonline,tosupportthelearningrequirementssetoutinthecurricula
toreviewcurrentstrategiesusedtoattractyoungdoctorsintoacareerinpathology,andidentifyfurthermeasurestheRCPAcouldundertaketopromotepathologyasacareer
Stage4requiredthefinalisationofrecommendationsforthepathologyprofessionandthedevelopmentofstrategiestoimprovethetrainingofpathologists
toproviderecommendationsregardinghowtoassessUKFellowstoenablethemtoobtainRCPAFellowshipwithoutexaminations.
These aims and objectives were achieved by this project although reviewing strategies to develop educational resources required further substantial resources. Outcomes Curriculum Review Thereviewforstage1waspreparedbytheCurriculumDevelopmentOfficer
andpresentedtotheBoardofCensorsoftheRCPAon10July2009.Thereporthighlightedthefollowingcharacteristicsofbestpracticecurriculaincluding:
o explicitcompetenciesrequiredforallaspectsofprofessionalpracticeo basingtheassessmentprogramonablueprintwhichmapsoutcomes
againstthemethodsbywhichtheywillbeassessedtoensureconstructivealignmentbetweenoutcomesandassessment
o arangeofvalid,reliable,feasibleworkplace-basedassessmentmethodsforformativeassessment
o suitablelearningexperiencesfordevelopingthedesiredcompetencieso emphasisingtheimportanceoftraineesreceivingregular,supportive
diagnosticfeedbackfromavarietyofsourcesbeforefinaljudgementsaremadeabouttheirperformance
o arangeofvalid,reliablemethodsformakingsummativejudgementsofcompetenceacrosstherangeofeducationoutcomes
o notassumingthatproficiencydevelopsafteraparticulardurationoftraining.
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Disciplinarypanelsrevisedtheircurriculainrelationtobestpracticeincludingdevelopingclearoutcomestatements.Theythendevelopedblueprintsforassessmentbasedupontherevisedcurriculatoconsiderreducingtheoverallloadofformalsummativeassessment,replacingsomeexistingassessmentwithmorereliableformsofassessment,andabroaderrangeofin-trainingandformativeassessmentenhancingopportunitiesforfeedbackandearlyremediationofproblems.
TheBasicPathologicalSciences(BPS)curriculumwasextensivelyrevisedwithmoreexplicitdefinitionoflearningoutcomes.Essayquestionshavebeenreplacedwithmultiple-choicequestions(MCQs)mappedtothelearningoutcomesintheexamination.
Extensivestakeholderconsultationanditerativerevisionshavecontributedtothedevelopmentofthenewmicrobiologycurriculumaccompaniedbyaportfolioincorporatingdocumentationoflearningactivitiesandoutcomesandasuiteofworkplace-basedassessmenttoolswhichweretrialedin2011.
Restructuredcurriculahavebeendraftedforanatomicalpathology,chemicalpathologyandimmunology,withotherdisciplinesunderdevelopment.
TheCurriculumDevelopmentOfficerhasbeenworkingwiththeChiefExaminerinanatomicalpathologyandotherstodevelopacurriculumforaDiplomainPaediatricPathology.
CurriculummappingforeachdisciplinewithdefinedparametersfordevelopmentofWPBAtools,withprocessesinplacetofacilitateearlyrecognitionandremediationofproblemswithtraining.
Examination Processes Examinationprocessesweremodifiedinmicrobiologytoprovidemore
authenticandreliableformsofassessment.EssayquestionswerereplacedwithMCQsandshortanswerquestions.Examinertrainingvideoswereproducedandusedforthe2010structuredoralexaminations.
Supervisor’sreportsarebeingmodifiedinalldisciplinestoclarifyoutcomesandstandards,toaccommodatedocumentationofworkplace-basedassessment(WPBA)andtoenableinputfrommorethanonesupervisor.
ApeerreviewpathwayhasbeendevelopedtofacilitatetheprogresstoFellowoftheRoyalCollegeofPathologistsofAustralasia(FRCPA)forpathologistswithqualificationsandexperiencethataresubstantiallycomparabletothestandardsforRCPA-trainedpathologists.
TherewillbecontinuedeffortstoreducetheoverallburdenasWPBAareestablishedtoimprovethereliabilityofexaminations,clearlyarticulatingstandardsandimprovingtheselectionandtrainingofexaminers.Thiswillbecompletedbytheendof2011andwillbefollowedbyongoingevaluationandreview.
Aprocessisinplaceforrigorouspeer-assessmentoverthecourseof12monthsofsupervisedpracticeforUKFellowsinanatomicalandchemicalpathology.Otherdisciplinesmayalsoofferthisassessmentfollowingmoreextensivereviewofanindividual’spasttrainingandexaminations.Considerationisbeinggiventoapplyingsimilarprocessestoothercountries.
Educational Resources TheMoodlelearningmanagementsystemasaplatformforatrainee
educationportalhasbeeninstalledtoofferconvenientaccesstolearning
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resourcesineachdiscipline.TheprogramQuestionmark PerceptionhasbeenpurchasedtointegratewithMoodlewhichwillfacilitatethebankingofassessmentitemsanddeliveryofonlineformativeassessments,aswellasconstructionofinteractivecasestudiesandmockexams.
OnlinelearningmaterialshavebeenmadeavailabletosupportpreparationfortheBPSexaminationwithanonlinemockexaminationavailableinearly2011.Existingresourcesforalldisciplinesisbeingrevisedforthenewonlineenvironment.Furtherresourcesarebeingplannedinaccordancewithneedsanalysisandpriority.
Training ThestudyreviewedhowtheRCPAmaybebetterabletoprovidetrainingfor
pathologistsindifficulttoservicelocations,includingregionalareas,andtodevelopastrategicplantoaddresstheseissuesandidentifycurrentobstaclesandpossiblesolutionsforovercomingthem.TheonlineenvironmentwillhelpwiththeseissuesandtheworkisbeingfurthersupportedthroughanAustralianGovernmentgrantundertheSpecialistTrainingProgram.Similarstrategiesmaybeusedtosupplementeducationandtraininginidentifiedareasofsub-disciplineshortages.
TheReviewofInternationalandNationalApproachestoPathologyTraining,andtheidentificationofareasthatareconsideredbestpracticeforpathologytrainingforAustralia,formsthebasisofaplanforongoingdevelopmentofanoutcomes-basedcurriculum.
Pathology as a Career Choice FundingfromthisprojecthassupportedtheengagementoftheDirectorof
Educationwithanumberofstrategiestoaddressattractingyoungdoctorsintoacareerinpathology.Theseinclude:
o formingaMedicalSchoolTaskforcetoidentifyopportunitiestoworkconstructivelywithmedicalschoolstopromoteandsupportqualityteachingofpathologyandengagestudents’interestinpathologyasacareer
o theRCPAactivelysupportinganadvancedstandingpathwayformedicalstudentsattheUniversityofNewSouthWales(UNSW)
o computer-basedsimulationsmayalsopromotepathologytodoctorsattheprevocationallevel
o thedevelopmentoftemplatesforpathologyrotationsforpost-graduationyearone(PGY1)andPGY2doctors
o theBoardofEducationcurrentlyreviewingcriteriaforofferingscholarshipsandsupporttomedicalstudentswhoundertakepathology-relatedprojectstoprovidegreaterincentives
o RCPAparticipationinCareerDaysatuniversities,high-schoolsandothernationalcareerevents
o theproductionofbrochures,vodcasts(onYouTube)andposterspromotingpathologyasacareer.
Finding Standardsettinganditemanalysisprocedureshaveimprovedthefairness
andreliabilityoftheexaminationintheBPScurriculum,andelectronicmarkingallowsmuchfasteravailabilityofresults.
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Recommendations 1. TheappointmentofanEducationDesignertodevelopanonlinelearning
environmentandfacilitatethedeliveryofonlineeducationalresources.2. FurtherstaffsupportmaybeneededasWPBAarerolledout,andtherewill
beaneedtotrainsupervisorsandexaminersandtoassistwithmonitoringandevaluationofongoingdevelopments.
3. Thedevelopmentofeducationalresourcestosupporttherevisedcurriculumisunderwaybutwillrequiresubstantialongoingfundingandhumanresourcestocontinuetheworkofconstruction,editinganduploadingofresourcesforsupervisors,examiners,workplaceassessorsandinternationalmedicalgraduates.
4. Developmentandimplementationofstrategiestoreviewandqualitycontroltheeducationalresourcesisamajorprioritythatwillrequireongoingexpertinputfrompathologists.
Areas for Future Consideration TheDirector,Educationwaspreparingastrategicplanatthetimeofthe
reporttoidentifyfutureprioritiesfortechnologiestosupportongoingeducationalneeds.
Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) Description Thisstudysoughttoidentifywaysinwhichworkloadimpactsonprofessionalpathologypracticethroughthreecomponentsdesignedtoprovideaworkforceperspective,maximisetheutilisationofMedicaredataandprovideaperspectiveoftheindividualpathologists.Thesewere:
1. identificationoftherelativetimevaluesofpathologists’workviatheMedicareSchedule
2. asurveyofthetotalworkloadofindividualpathologistsoverayearusingMedicarebillingandrelativetimevalues
3. adiarythatidentifiedthetimespentonindividualitemsbyparticipatingpathologistsoveragivenweekincludingasurvey(theDiarySurvey)oftheimpactofexistingworkloadonqualityandsafetyofpathologywork,includingtheimpactonthehealthofpathologists.
Therearealsonocurrentbenchmarksforstaffingandworkloadforpathology. Grant Recipient RoyalCollegeofPathologistsofAustralasia(RCPA)Aims and Objectives todevelopabetterunderstandingofhowthequalityandsafetyofpathology
servicewerebeinginfluencedfromtheperspectiveofAnatomicalPathologists
toaddresstheimpactofworkforceshortagesinthequalityandsafetyofpathologyservicesinAustralia,andtheimpactonpathologists.
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These aims and objectives were achieved by this project. Outcomes Pathologists(65outofthe96surveyed)identifiedthefollowingareasthat
couldbechangedtoimprovethequalityandsafetyofpathology:o morepathologistso lessworkload/safeworkloadlimits,betterbalancedworkloado betterinformationtechnology(IT)infrastructure/supporto moretimeforprofessionaldevelopmentactivities/readingo betterreimbursement/improvedremunerationper
specimen/improvedremunerationbyMedicareo morescientific/technicalstaffo moresecretarialsupport/clerical-adminstaffo moretrainees.
AworkshopofseniorexperiencedpathologistswasconvenedtoprovideexpertopinionintotheRelativeTimeUnits(RTUs)foritemsontheMedicareBenefitsSchedule(MBS).Theactualtimereportedinthediarieswaslessthantheestimateofbestpracticeidentifiedintheexpertworkshop,however,thesemaybeaduetoreasonssuchastestingtaskssuchascut,qualityassuranceandcaseconferencebeingmeasuredseparatelyinthediary.
Followingthisworkshop,asurveyofpathologists’annualworkvolumewasundertakenwhichfoundawidedistributionofclinicalworkloadrangingfromlessthan200RTUstoover3000RTUswithanaverageof1,439RTUs.
Findings Pathologistsareunabletofullyundertakequalityassuranceactivitiesdueto
excessiveworkloadswhichrepresentsapotentiallyseriouspublichealthconcern.
Thepathologists’surveyedreportedthatanincreaseinworkforcenumbersisrequiredtosustainexistingworkloadsandaddresstheissuesofqualityandsafety.
WhiletheRCPAhasbeensuccessfulinincreasingthenumberoftrainingplacesforpathologistsinAustralia,thereappearstobeadisconnectwithrecruitmentatspecialistlevelforgraduatingpathologistswhichmeanstheincreasednumbershavenottranslatedintoanimprovementofspecialistworkloads.
Full-timepathologistsworkedanaverageworkingweekof48hours,whilethosewhoworkedlessthanfull-timereportedaworkingweekof34.7hours.
43%ofpathologistswhokeptadiaryforaweekreportedworkingsdaysof10hoursormore.
TheactualhoursrecordedintheDiaryweresubstantiallyhigherthanthereportedusualhoursworkedinaweekwhichsuggeststhatpathologistsmayunderestimatethehourstheywork.
55%ofpathologistsreportedtheywereworkingmorenowthantheyhadbeentwoyearsago.
24%ofpathologistsconsideredtheywereworkingabovetheircapacity,andasubstantialproportionstatedtheywereonlyabletosustaintheirworkloadforalimitedperiodoftime(23%forayear,38%fornomorethan2years).
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71%ofthoseworkingabovetheirfullcapacityindicatedtherehadbeentimestheyweretoobusytoqualityassuretheirwork,73%reportedtheirworkloadcompromisedqualityand45%reportedtherehadbeentimeswhenpatientcarewascompromised.Afurther51%workingatcapacityreportedtheirworkloadimpactedontheirabilitytoundertakequalityassurance(QA)activities.
41%ofthepathologistsinregionalcentresreportedsituationswherepatientcarehadbeencompromisedcomparedto17%ofthepathologistsincapitalcities.
Adversequalityandsafetyimpactsincreasedsharplywhenpathologistsworkedmorethan39hoursaweek.
68%ofpathologistsindicatedtheirworkloadhadimpactedontheirhealthandwellbeing,while91%ofthoseworkingabovetheirfullcapacityreporteditwasaffectingtheirhealthandwellbeing.Thefourmainareasmentionedwereincreasedstress,feelingconstantlytired,decreasedphysicalfitnessandimpactonpersonalrelationshipsoutsidework.
33%ofpathologistsinregionalcentresreportedincreasedturnaroundtimes,while17%ofpathologistsinthemetropolitanareasreportedincreasedturnaroundtimes.
8%oftheactualworkingweekofpathologistsisallocatedtoQAactivities. Thecriticalpointatwhichqualityandsafetyissuesappeartobemostatrisk
isafterthe39hoursperweekmark. Thereisastrongrelationshipbetweencapacityandthenumberofareasin
whichadversequalityandsafetyimpactsassociatedwithworkloadwereidentified.
Therelationshipbetweenhighworkloadandcompromisesinqualityandsafetyisasystematicissueandnotrelatedtopublicorprivatelaboratories,locationorpathologists.
Recommendations 1. Thereisastrongimperativetoestablishsafeworkingguidelinestoaddress
thecurrentdeficiencyforanatomicalpathologistsinAustralia.2. Thesolutiontoaddressingthequalityandsafetyissuesliesinaddressingthe
workforceshortage.3. Increasingthenumberofqualifiedpathologistswillnotsignificantlyreduce
theworkloadsofpracticingpathologistsunlessthenumberofspecialistpositionsisincreased.Thesecouldbefilledbytheincreaseintraineesgraduating,orbypracticingpathologistsmovingfromapart-timetoafull-timearrangement.TheRCPAwillneedtocollaboratewithAustralian,StateandTerritorygovernmentsandtheheadsofprivatelaboratories.
4. Ongoingmonitoringoftheworkloadisrequired.OnemethodisforindividuallaboratoriestousethetoolsdevelopedinthecourseofthisprojecttorefineRTUestimates.
5. Ensuringgoodoccupationalhealthandsafetypracticeswithinlaboratoriesisasoundstrategyforassistinginminimisingtheimpactofworkload.
Follow on Initiatives and Projects TobetakenupbytheWorkforceAdvisoryCommitteeandthisissuewasalso
specificallyidentifiedasaninitiativeinthePathologyFundingAgreement.
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Areas for Future Consideration Continuetomonitortheworkloadforpathologists.
Survey of the Pathology Workforce (2011) Description Thisprojectprovidedasnapshotofthe2010pathologyworkforceasreportedbyparticipatingpathologyworkforceemployersandemployees.Theprojectreportidentifiedanumberofstatisticsrelatingtothepathologyworkforce,withonlythemainpointsincludedinthissummary.Grant Recipient URBISAim todescribeincompleteandaccuratetermsthesizeandmake-upofthe
AustralianPathologyworkforceintermsofkeyworkforcegroupings,demographiccharacteristicsandworkplacecharacteristics.
Objectives reviewexistingpathologyworkforcedatacollections,methodologiesand
surveyinstrumentsandincorporatethelearningsintothedevelopmentofaneffectivemethodonwhichtoconductthefirstevernationalpathologyworkforcesurvey(Survey)
finalisethelistofrequireddataitemsforinclusionintheSurveyinconsultationwiththeprojectsteeringgroupandprojectreferencegroup
developSurveyinstrumentstocollectthedatainconsultationwiththeprojectsteeringgroup
developanimplementationstrategyfortheSurveywithpathologyproviders/employerstonegotiateagreeabledatacollectionmechanismsandtomakearrangementsfordatacollection
collect/coordinatethecollectionofdataandmanagequalitycontrol clean,processandanalysedata developacurrentpathologyworkforceprofile conductanauditofeducationalinstitutionsinordertoascertainthecurrent
supplysourcesforidentifiedworkforcegroupings identifystrategiesforongoingmonitoringofthepathologyworkforce.The aim and objectives were achieved by this project. Outcomes The2010PathologyWorkforceSurveycaptureddatathatcoveredthe
followinggroupsthroughtheuseofanemployersurveyandanemployeesurvey:
o pathologistso scientistsandseniorscientistso medicallaboratorytechnicianso laboratoryassistants
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o healthinformationprofessionalso phlebotomists/pathologycollectorso mortuaryattendantso courierofpathologyproductso clerical/clericalsupporto management&supportservices.
Therewereatotalof4,743responsestotheemployeesurvey,whichwasreducedto4,631(Table8)oncethemissingdatapointswereexcluded.Thisrepresentsabout20%oftheestimatedpathologyworkforce.
TABLE 8 – SAMPLE SIZE WORKFORCE GROUP FREQUENCY %
Pathologist (includes Specialists and Trainees) 359 7.8% Senior Scientist 334 7.2% Scientist 2,308 49.8%
Laboratory Technician 572 12.4%
Laboratory Assistant 273 5.9% Health Information Professional 80 1.7% Phlebotomist/Pathology Collector 390 8.4%
Medical/Anatomical Pathology typist 146 3.2% * Other pathology 169 3.6% Total 4,631 100% * A breakdown of ‘Other pathology’ includes those mainly performing administrative functions (n=27) and assistant/aid functions (n=22). This was followed at much lower levels of mention by academic/teaching functions (n=13), clinical functions and warfarin (both n=13) and quality management functions (n=12). All other mentions were lower than n=10.
Atotalof28employersurveyswerecompletedrepresentinga22%response
rateofalltheApprovedPathologyAuthorities(APAs)(Table9)contacted(n=130)
TABLE 9 – NUMBER OF EMPLOYEES IN APAS NUMBER OF EMPLOYEES NUMBER OF APAS CUMULATIVE NO. OF APAS
Fewer than 15 6 6 15-80 5 11
81-500 10 21 501-1,500 5 26 Greater than 1,500 2 28
Oneverylargeorganisation(morethan1500employees)declinedto
participateintheemployersurveywhichmayhaveactedasadiscouragementtostaffparticipation.
AbriefauditofAustralianeducationalinstitutionswasconductedoveraneight-weekperiodtogaugetheextenttowhichtheeducationsupplymeetscurrentandanticipatedfutureworkforcedemand.
Findings Theestimatedsizeofthepathologyworkforceis24,157. Thereweresignificantdifferenceswithinage,genderandlocationbetween
workforcegroupsbetweenstates. Notableresponsesrelatingtojob/workplaceindicatedthat43%ofsenior
scientistsintendedtoleavethepathologyworkforceinthenextfiveyearsand58%ofspecialistpathologistsworkedmorethan45hoursperweek.
Ittakesabout3.1monthstofillthevacantpositionsofscientists.
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Themainreasonforpathologistsintendingtoleavetheprofessionwereduetoimpendingretirement(73.5%)comparedtothoseinotherpathologyworkforcegroupings,andtheyweremuchlesslikelytobeseekingachange/employmentinanotherprofession(1.5%)orfeeltheyhadlimitedcareeropportunities(0.0%).
Themostpressingissuefacingthepathologyworkforceistheshortageofskilledlabour(particularlyseniorscientistsandpathologists),whichwasmentionedbyallAPAscompletingthesurvey.Theyalsonotedthegenerallackofinterestamongsomescientiststoundertakefurtherpersonaldevelopment,andtheneedforseniorscientiststostep-upandrunlaboratories.
Thelackofseniorpositionstoprogressandpromotestaffwasalsoidentifiedasacurrent‘bottleneck’exacerbatingtheskilledlabourshortage.
Thereisalsoashortageofhealthinformationprofessionals,possiblyduetotheaccelerationofeHealthinitiatives.
Othersecondaryissuesincludehighstaffturnover(particularlyamongstphlebotomy,clericalandreceptionstaff),thetimeframestoreplacestaff,andtheexpenseofprovidingpracticalon-the-jobtraining.
ThereisanunevenspreadofjobsacrosstheStates,witharound50%oflaboratorytechnicianslocatedinNewSouthWales,whilethereisahighconcentrationoflaboratoryassistantsinQueenslandandsignificantlyfewerinVictoriaandSouthAustralia.
Otherissuesincludeinsufficientincentivetoattracttherightpeoplefrommetropolitanareastomoveintoandworkinsmallerregionalcommunities(e.g.pathologyregistrars),poorMedicarerebates,highcostofwagesinamarketofdecliningrevenues,difficultystaffingout-of-hoursshifts,thedesireamongstseniorstafftoworkfewerhoursandtheneedformoreefficientworkpractices.
About20%ofemployeerespondentsintendtoreducetheirworkinghours,withpathologists(34%)returningthehighestincidenceinthisgroup.
Thesizeandeffectivenessofthefuturepathologyworkforcewillbelargelydeterminedbytheprovisionofsuitablyqualifiedentrantsintotheworkforce,particularlyataseniorlevel(e.g.pathologists).
Recommendations 1. Thereisaneedtocreatemorepositionsandworkplaceopportunitieswhile
alsomakingpathologyanattractivecareerchoiceinordertofillthesepositions.Thisneedismorepressingatthehighlyskilledendofthejobspectrum,particularlyforpathologistsandscientists.
2. Tosuccessfullyattractnewpeopleintoacareerinpathologytheprofessionneedstobemademoreattractivethroughpositivestructuralchange(internalfocus)aswellasthedevelopmentofamarketingcampaigntopositivelyadvertiseandpromotetheindustry.Animportantaspectofthisshouldbetheactivepromotionofregional/ruralplacements.
3. TheMedicalBenefitspayableforpathologyshouldbeincreased.4. Aflexibleandeffectivemanagementstructurethatallowsforsuccession
planning,intelligentrotations,providesworkreplacementfortrainees,maximisesthenumberofworkplacetrainingpositionsandalignsthestrategicgoalsoftheorganisationwithworkforceissuesshouldbeprovided.
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5. Improvecommunicationandcoordinationwithtertiarycourseproviderstoensurethatgraduatesarebetterabletomeetjobrequirementsbasedontrainingthatisrelevantandpractical.ThisprocessshouldalsohelpAPAsattractbettergraduates.
6. Createpaidpositionsforscientiststhatarenotdirectlyrelatedtoresultoutputs.
7. Introduceinitiativestohelpovercomethesignificantshortageofscientistsincludingtheprovisionofscientistapprenticeshippositionswiththeassistanceofcooperativegovernmentfunding,supportingmedicalscientists’careerstructureinitiativesandprovidingsupportforrestructuringtheawardforscientists.
8. Providesustainabletrainingbyallocatingsufficientfundingfortrainingpositions,andensuretrainingremainsatopagendaitemgoingforwards.
9. Continuingtolobbyforindustrybestpracticeonanumberoffrontsincludingtertiaryinstitutions(forbettertraining/betterqualifiedgraduates),medicaladministrators(forbettermedicalandpathologytraining)andtocontributetoworkforcereformandtheseparationofindustrialversusprofessionalissues.
10. Offergoodremunerationandcareerprospectstoattractnewpeopleintopathology,andtomakeitmoreappealingforpart-timeworkerstoworklongerhours.
Key Project Learning Developinganeffectivemethodologyforthisprojectwaschallengingdueto
thefacttherewasnotadirectandstraightforwardmeansofgainingaccesstoallworkersinthepathologysector.Therewereonlyalimitednumberofprofessionalassociationsandindustrypeakbodiesbothableandwillingtoprovideaccesstosegmentsofthepathologyworkforce,butnonewhichrepresentedallpathologyworkers.
Follow on Initiatives and Projects CareerStructuresandPathwaysfortheScientificWorkforceinMedical
PathologyLaboratories PathologyWorkforceWorkshoponpage177.Areas for Future Consideration Investigatestrategiestopromotepathologyasanappealingcareerchoice. Investigatestrategiestoprovideincreasedaccesstopathologytopeoplein
ruralandregionalareas.
Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011) Description ThisprojectanalysedthescientificworkforceandproposedamodelforacareerframeworkfortheAustralianscientificworkforceinmedicalpathologylaboratories.Thescientificworkforceisdefinedasincludingseniorscientists,medicallaboratoryscientists,medicallaboratorytechniciansandlaboratory
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assistants,althoughindividualswithineachworkforcegroupmayholddifferenttitles.Grant Recipient HumanCapitalAlliance(HCA)Aims and Objectives toprovideanunderstandingofcurrentandfutureworkforcerequirements
andtheappropriatenessandadequacyofcurrentsupplystrategies toinvestigateoptionstopromoteworkforceretentionespeciallythrough
careerpathwaysdevelopmentforthescientificworkforceinmedicalpathologylaboratories.
These aims and objectives were achieved by this project. Outcomes Aone-dayworkshopwasheldon24November2010withall12membersof
theProjectReferenceGroup(PRG). Secondarydatasourcesweregatheredandanalysed. Aliteraturesearchwasconductedtoresearchcurrentpractices,specialist
viewpointsofspecialistsandsurveyreports. Writtensubmissionswereinvitedfromselectedstakeholders,andextensive
stakeholderconsultationswereundertaken. Areviewofawardstructuresfromvariousstateswerecollectedand
analysedforsimilaritiesandcompatibilitieswithspecialattentionpaidtotheprosandconsofeachinregardtopotentialcareerframeworks.
Aone-dayworkshopwasheldwiththePRGtofinalisetheproject. Majorissuesidentifiedandexploredinclude:
o workforceboundariesaroundthemedicalpathologyscientistworkforce,andwithintheworkforcebetweenassistants,techniciansandscientistsandbetweendifferentdisciplines
o apparentlabourmarketconditionsandthepossibilityofsegmentedlabourmarketsthatbehaveindifferentways,andtheimplicationsfornewgraduatesupply,preferredtrainingprovidersandpreferredcareerstructurestofosterearlycareers
o deskillingofcertainlabourmarketsasaresultofcentralisingtestingprocesses(rural/private)
o useofcompetenciesasameansofunderstandingskillandknowledgeincomparisonwithqualificationsandhowthesemightbetterunderpinarangeofhumanresourcedecisions
o someaspectsofscientistworkforcebehaviourthatareimpactingonavailablesupplyandhaveimplicationsforcareerframeworks,suchashighturnoverofscientistsatspecificlevelsandtimeperiods,andincludingthoseassociatedwithscientists’progressionbeyondthefirstfivetosevenyearsinemploymentandbarrierstoentrytoseniorscientistlevels
o limitedpoolof‘middlelevel’scientistsabletoprogresseasilytoseniorscientistrolesasitisexpectedthatlargenumbersofseniorscientistwill(shortly)reachretirementageandexittheworkforce
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o variedpossiblepathwaystoseniorscientistlevels,butinmostcasesthereisanimplicitrequirementorspecificcommitmenttomanagementdevelopment.Thisisunattractiveformanypotentialcandidates
o supportforclinicalseniorscientistroleswheresuchrolescanbedefined,particularlyindisciplinesinwhichpathologistnumbersandinfluencearelow
o arangeofcareerstructurepossibilitiesthathavealreadybeenexploredbyemployersorprovidedbypersonsthinkingabouttheissue.
Findings Themostcompleteandcompellingcareerstructuremodelforthescientific
workforceinmedicalpathologylaboratorieshasbeendevelopedandimplementedintheUK.Itisbuiltontheconceptofskillsescalationandoffersflexiblecareeropportunitiestomeetworkforceserviceandindividualneeds.
ThePathologyAssociationsCouncil’s(PAC’s)setofcompetencystandardsforthescientificworkforceinmedicalpathologylaboratoriesrepresentanunder-utilisedresourceforimprovingthedevelopment,managementandassessmentofthemedicalscienceworkforce.
AcredibleandcurrentestimateofworkforcesizeisrequiredthrougheitherMedicareAustraliaortheNationalAssociationofTestingAuthorities(NATA).
ManyofthedifferencesintheAustralianscientificworkforceinmedicalpathologylaboratoriescareerframeworkscanbeattributedtoorconsolidatedbyprevailingindustrialarrangements.
Careerprogressioninthepublicsectordependedonapositionbecomingvacant(scientistsoccupyingseniorroleswereoftenincumbentforanextendedperiodoftime),whileintheprivatesectoritwasatthediscretionofmanagement.
Themedicalpathologyscientistworkforceisclosestinstructuretothenursingworkforcewiththreediscernablelevels;professional,paraprofessionalandsemi-skilled.
Thereareinsufficientnumbersofseniorscientistpositionstoprovideareasonableincentivetoscientiststoinvestinthepursuitofoneofthesepositions.
Anycareerframeworkforthemedicalpathologyserviceworkforceshouldsatisfythefollowingprinciples:
o thecareerframeworkshouldbecomprehensiveandincludeallcomponentsoftheworkforce.
o introducecompetencybasedprocesses,calibratedagainstcompetenciesinsteadofqualifications,tosupportcareerframeworkstructures.
o thearticulationofcareerpathwaysshouldbeclearandtransparentandnotsubjecttodiscretionaryjudgements
o learningopportunitiesshouldbebuiltintothecareerframework. Itisunlikelythatasinglecareerframeworkwouldbeappropriatetofitallof
thedifferentcircumstancesinvariousmedicalpathologylaboratorysciencelabourmarkets.
Recommendations
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1. UtilisethePathologyAssociationsCouncil’ssetofcompetencystandardsusingtheeightpathwaysidentifiedinthereport:
01. reviewcurrentindustrialarrangements02. supportthewideruseofcompetencieswithintheworkforce03. exploreandassessthefeasibilityofdifferentapproachestobuild
currentdataonworkforcenumbersandskillmix04. builddataonservice/labourdemand05. undertakelabourmarketanalysis06. supportstructuredtrainingforseniorscientists07. clinicalpracticefornewgraduatescientists08. trainingoftechnicians.
2. Recommendationsarisingfromconcernsassociatedwithcareerframeworkchangeinclude:
o thereisaneedforatleasttwopathwayswithinacareerframework–managementcompetenciesandcontinueddevelopmentofexpertiseasascientist
o thetransitionfromeducationtoworkisunstructured,andgraduatetraineepositionsshouldbereinstated
o reinstateapprenticeshiportraineeshippositionstosupportthetrainingoflaboratorytechnicians
o progressfromnovicetoproficientpractitionerforscientistsshouldbe‘mapped’againstidentifiedcompetencies,andsubsequentpayrises,promotionsandworkallocationallmadeconsequenttoassessedlevelsofcompetence
o introducearegistrartypetrainingprogramtoenablethetransitionfromproficienttoexpertpractitionerforscientists
o lengthenthecareerpathwayofmedicalscientistsbyintroducingextendedpracticeroles.
3. Apowerfulreasontochangeandseeknewcareerframeworksisnecessarytoovercomebarrierstochange.Benefitsneedtobehighlightedtoemployersthroughrelevantforums(e.g.NationalCoalitionofPublicPathology[NCOPP]andAustralianAssociationofPathologyPracticesInc.[AAPP])anddirectlytoemployersthroughbusinesscasestudiesofattemptedcareerframeworkchange.
4. TheoutlineofpossiblecareerframeworkforthescientificworkforceinmedicalpathologylaboratoriescanbefoundinFigure8onpage73ofthereport.
Follow on Initiatives and Projects FurtherpossibleworkthroughtheWorkforceAdvisoryCommitteeunderthe
PathologyFundingAgreement.Areas for Future Consideration InvestigateavenuestopromoteandutilisethePathologyAssociations
Council’ssetofcompetencystandardsusingtheeightpathwaysidentifiedinthereport.
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Consumer Focus and Information Strategies TheQualityUseofPathologyProgram(QUPP)soughttoengageconsumersinameaningfuldialoguetoincreasetheirknowledgebaseaboutthequalityuseofpathologyandidentifyconsumerissuesrelatedtopathology.Thiswasachievedthroughthreeprojects(Table10)whichhighlightedtheincreasingimportanceofengagingwithconsumersaslegitimatestakeholdersinthehealthsystem.Theseprojectsrevealedconsumerissuespredominantlybasedonaneedforimprovedcommunicationandengagement,especiallyaroundthebenefitsandrisksofpathology,andtheneedforcomprehensiveinformationstrategiestoaddresstheirconcerns.Asaconsequence,areasforfutureconsiderationidentifiedthroughthisintegratedanalysisinclude: Bestpracticeweb-basedguidelinesforconsumersregardingpathologyself-
collections. Informationstrategiestoinformconsumersaboutthestatusandprogressin
theareasofeHealthandruralandremoteissues. Developmoreinformationresourcesforthewebsite
www.labtestsonline.org.au(LTOAU). Implementaconsistent,ongoingcommunicationcampaigntoinform
consumersandhealthcareworkersabouttheexistenceofLTOAU,highlightingitasanindependent,trustworthysourceofinformationaboutpathology.
[alt=“ThefollowingtableliststhethreeprojectnamesandgrantrecipientsundertheConsumerFocusandInformationStrategiestheme”] Project Name Grant Recipient/s 1 QualityUseofPathologyConsumerConsultation
Project(2010)ConsumersHealthForumofAustralia(CHF)
2 BenefitsandRisksofPathologyTesting(Current) RoyalCollegeofPathologistsofAustralasia(RCPA)
3 LabTestsOnlineAUStage1(Current) AustralasianAssociationofClinicalBiochemists(AACB)
Table10:ReportsSummarisedforConsumer Focus and Information Strategies
Quality Use of Pathology Consumer Consultation Project (2010)
Description Thisprojectsoughttoengage,informandconsultwithhealthconsumerstoidentifyissuesofimportancetoconsumersregardingthequalityanduseofpathology.
Grant Recipient ConsumersHealthForumofAustralia(CHF)
Aims
toestablishanevidencebasethroughconsumerconsultationtoidentifyconsumerissues,includinggapsandopportunitiesandfacilitatorsandbarrierstoqualityuseofpathology
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tosuggeststrategiesthatwouldmakethepathologyexperiencemoreappropriateforconsumers.
These aims were achieved by this project.
Outcomes
AseriesofeightjurisdictionalworkshopswerecarriedoutacrossAustraliainlate2009.
AnationalworkshopwasheldinMelbourneinMarch2010whichbroughttogetherconsumersandpathologystakeholderstodiscussissuesraisedinthejurisdictionalworkshops.
Continuedinputwassoughtfromconsumers.
Findings
Issuesdiscussedinconsultationsincluded:o safetyandqualityofserviceo equityofaccessincludingavailabilityandaffordabilityo adequateavailabilityofanappropriateworkforceo communicationbetweenconsumer,referrerandprovidero privacyo PointofCareTesting(PoCT)andcosto DirectAccessTesting(DAT)o rural/remoteissuesthatrelatetopathologyo eHealthandaccesstopathologyresultso genetictesting.
Twokeyissuesidentifiedbyconsumersweretheimportanceofimprovingconsumerhealthliteracy,andtheneedformoreandbetterinformationtobecommunicatedtoconsumerspriortotesting.
Consumerswerealsoconcernedabouthowtobestensureallconsumersreceivethisinformationincludingthosefromculturallyandlinguisticallydiverse(CALD)backgrounds,peoplewithdisabilitiesandthosewithlowliteracy,giventhedemandsonthetimeofGeneralPractitioners(GPs)andSpecialists.
Itwasalsoseenasessentialthattheinformationprovidediscorrect,clear,up-to-dateandcomprehensive,andthatconsumershavetheopportunitytoseekadditionalclarifyinginformation.
Recommendations 1. Thedevelopmentandimplementationoftoolstoprompthealthpractitioners
toprovidebetterqualityinformationforthoseundergoingorconsideringpathologytesting.
2. ThedevelopmentandprovisionofgenericQualityUseofPathology(QUP)informationtoconsumers.
3. Thedevelopmentofresourcestoenhanceself-managementskillsandcapabilitiesforconsumers.
4. Promptaccesstoresultsforconsumersandpromptexplanationoftheirmeaningfollowedbywritteninformationonthoseresultsandsubsequentrecommendations.
5. IntroductionofaMedicareItemNumberfora‘PathologyResults’consultationwithaGPorotherrequestingpractitioner.
6. InvestigationofmorewidespreadimplementationofPoCT.
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7. Workforceinitiativestodealwiththeshortageofexpertise.8. Increasedfundingtoaidtheexpansionofmobilecollectionservicestomore
ruralandremotecommunities.9. Improvedavailabilityoftelemedicineservices,particularlyforthe
explanationofresults.10. Agreateremphasisoninformedfinancialconsentforpathologyservices.11. Ongoingconsumerconsultationandinputintoanychangestocurrent
pathologyfundingarrangements.12. Creationofstrongerlinkswithotheraccreditationprocesses.13. Implementationofatransparentcomplaintsprocesstoencourageand
reviewconsumercomplaintsinrelationtopathologytesting.14. Credentialingofthepeoplewhocollectsamplesatcollectionscentres.15. ContinuedconsumereducationabouttheroleofeHealthinimproving
privacybyenablingsecureelectronictransmissionofinformation,andthebenefitstoconsumersinimprovingcommunication,efficiency,safetyandquality.
Key Project Learnings
ConsumersacrossStatesandTerritoriesexpresseddifferingexperiencesandviewsonwhatiscurrentlyoccurringinthepathologyfield,andalsoaboutwhattheyhopedtoseehappeninthefuture.
Consumersagreedontheneedforquality,safe,accessibleandaffordablepathologyservices.
Consumersexpectprovidersandpractitionerstolistentothemandconsidertheirviewswhenmakingpathologyrequests,takingsamplesandconveyingresults.
Consumersbelievepathologyisanareawherefurtherworkneedstobeundertakenwithconsumers.
Follow on Initiatives and Projects
BenefitsandRisksofPathologyTesting EffectiveCommunicationofPathologyResultsinRequestingPractitioners
andConsumersonpage133 BestPracticeinPathologyRequestingandReportingWorkshoponpage175.
Areas for Future Consideration
Bestpracticeweb-basedguidelinesforconsumersregardingpathologyself-collections.
InformationstrategiestoinformconsumersaboutthestatusandprogressintheareasofeHealthandruralandremoteissues.
Benefits and Risks of Pathology Testing (Current)
Description Thisprojectisseekingtoincreasetheknowledgeofconsumersaboutthebenefitsandrisksofpathologytosupportmoreinformedengagementofconsumersinthepathologytestingprocess.Thesteeringcommitteeincludedrepresentativesfrom:
o ConsumersHealthForumofAustralia(CHF)
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o LabTestsOnlineAU(LTO)Boardo PathologyAssociationsCouncil(PAC)o RoyalAustralasianCollegeofPhysicians(RACP)o RoyalAustralianCollegeofGeneralPractitioners(RACGP)o RoyalCollegeofPathologistsofAustrasia(RCPA)(pathologistandLay
Committeerepresentatives)o DepartmentofHealthandAgeing(DoHA).
Grant Recipient RCPA
Aims and Objectives
toproduceaconsumer-focusedAustralianpublicationbasedontheconceptoftheUKpublicationSense About Science – Making Sense of Testing(http://www.senseaboutscience.org/data/files/resources/6/Making-Sense-of-Testing.pdf)
toeducatethepublicaboutpathologytestinginaneasy-to-readformatbasedonsoundscientificprinciplesandfocusingonasetofkeyidentifiedrisksandbenefits.
This project is current and these aims and objectives are in the process of being achieved.
Outcomes
Ninefactsheetsarecurrentlyinthefinalstagesofproduction.Theseare:1. Whoworksinpathologyandwhatdotheydo?2. WhydoIneedapathologytest?3. Consent–Whatyouneedtoknow4. WherecanIhaveapathologytest?5. Howsafeisthetestingprocess?6. WhatshouldIknowaboutpathologytestresults?7. Howarepathologytestfeescalculated?8. WhatshouldIknowaboutgenetictesting?9. WhatshouldIknowaboutDirect-to-Consumergenetictesting?
Lab Tests OnlineAU Stage 1 (Current)
Description ThisprojectisseekingtodevelopanauthoritativewebsitethatprovidesinformationonpathologytestsavailableinAustralia,anddrawsoninternationalcollaborationofpathologyexperts.TheLabTestsOnlineAU(LTOAU)websiteis:http://labtestsonline.org.au/.
Grant Recipient AustralasianAssociationofClinicalBiochemists(AACB)
Aims and Objectives
todevelopanauthoritativedatabasewhichisaccessibleasawebsitetothegeneralpublicandhealthprofessionals
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toprovideinformationonpathologytestsandthehealthconditionsthetestsareusedtodiagnoseandmonitor
todeterminetheneedsofthecurrentusersandnon-siteuserstoimprovethewebsitecontentandaccessibility
toexplorewaysofpromotingthewebsitemorewidelytohealthconsumersandhealthprofessionals.
These aims and objectives were achieved by this Stage 1 of this project.
Outcomes
Atwo-partresearchprojectwasimplementedbetweenJuneandNovember2011todeterminetheneedsofcurrentusersandnon-siteusersanddetermineattitudestowardspathologyingeneral,andmorespecificallytotheLTOAUwebsite.ThefindingsfromthissurveywillbeusedtodevelopsomeofthetasksinaproposedStage2ofthisproject.
Apartfromnewsitems,verylittleadditionalmaterialhasbeenaddedrecentlyasthebulkoftheeditorialworkloadcontinuestobeaddedatthethreeyearlysitereview.Thisprocessisnearingcompletionforalltestsandconditions.
Theprojectiscurrentlyinapublishholdphasetoexhaustivelycheckthewebsitebeforere-launchingthesitewiththenewcontentmanagementsystem.
Theinitiativeofusingtraineepathologyregistrarsisworkingwellandarecentlyretiredpathologisthasbeenrecruitedtostrengthentheteam.
Theprojectnowhasasustainablesolutioninplaceforthedeliveryofeditorialcontentacrossallofthepathologydisciplines.
Therehasbeenanaveragemonthlytrafficgrowthof4%resultingina42%increaseoverthepreviousyear.
Findings Responses to Consumer Research Survey Theresearchconfirmedthatinthefouryearssinceitslaunch,LTOauhas
beenavaluableassetinempoweringpeoplebygivingthemthereliableandtrustworthypathologyinformationtheyneedtoengageinproductiverelationshipswithmedicalandhealthprofessionals.Itisalsoanimportantinformationsourcefordoctors,nurses,practicemanagers,pathologycollectorsandhealthprofessionals,bothforthemselvesandtheirpatients.
Theresearchalsohighlightedfundamentalchangestakingplacewithinpathology.Accesstotestresultsisbecomingarealisticexpectationamongthepublicandthemedicalprofession,andthisisseenbyeventhemostconservativeandchange-resistantasapositivedevelopment.
Themedicalprofessionalsandmembersofthepublicwhotookpartintheresearchwerestronglyconcernedabouttheveracityofinformationoncommercialwebsites,withthepublicparticularlywaryofanyinformationfromoverseas.
Thetrendtowardsself-educationandmoreactivepatientparticipationinhealthcareisbeingembracedbysomesectionsofthegeneralandmedicalcommunitiesandresistedbyothers.
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Theresearchflaggedaclearneedforanon-commercial,trustworthysourceofpublicinformationaboutpathology.LTOAUhasestablisheditselfasthefirstpointofcallforpathologyinformation.
Theresearchalsohighlightedthatgeneralpractitioners(GPs)weremostlyagainstpatientsbeinginformedabouthealthmattersgenerally.
Theresearchnotedthatpathologycollectionstaffwouldliketoseethepublicbetterinformedaboutpathology,thetestingprocessandinparticularthecostandvalueoftesting.Theybelievethatifpeopleunderstoodthecostofpathologytestingthentheywouldvalueitmore.
OnegroupofSydney-basedhospitaldoctorsandnursesalsothoughttherewasanissueofdoctorsnotbeingfullyinformedabouttestsandwhofelttheneedto‘over-test’theirpatients.
Pathologycollectionstaffreportedmostquestionsfromthegeneralpublicrelatedtowhethertheywouldbebulk-billedforthetest,howlongittakestogetresultsandwheretheresultsweresent.
ManyGPsinthesurveyfeltLTOAUwasmoresuitableforthemandwasratedasthemostconcisesourceofinformationonpathologytestingreadilyavailabletoGPs.
GPsalsofounditdifficulttoacceptthesitewouldhavebeenwrittenwithoutsomeformofcommercialorgovernmentagenda.
MostpeoplefoundLTOAUbyGooglewhichhighlightedtheneedforaconsistent,ongoingcommunicationcampaigntopromoteitasareliableinformationsourceforpathology.
Recommendations 1. LTOAUneedstohaveclearerreferencestoitsauthorsandsponsorsand
clearlyarticulatethatthewebsiteisAustralian,independentandnon-commercialwiththeinformationpreparedbyexpertsworkinginpathologytesting.
2. Endorsementswillbenegotiatedwithrelevantgovernmentagenciesandrecognisablemedicalandprofessionalassociations.
3. TheAACBshouldstatetheircredentialsclearlytoreassuretheaudiencetheinformationhasbeenpreparedundertheauspicesofabodywiththeappropriateauthorityandexpertise.ThismayincludealinkonthebannertoasectionabouttheAACB.
4. Appointawebprofessional(thisisinprogress)toredesignandexplorewaysofpresentingtheinformationsoitiseasilyaccessible.Newcopywillalsobeprepared.
5. Thewebsite’scontentwillbereviewedbytheSiteManagerandtestedviaanonlinesurveyof40participantsincludingmembersofthepublicandmedicalandhealthprofessionals.
6. Allinformationwillbereviewedandrevisedandmademorereadilyaccessible.
Follow on Initiatives and Projects
Stage2ofthisproject.
Areas for Future Consideration
Developmoreinformationresourcesonthewebsite.
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Implementaconsistent,ongoingcommunicationcampaigntoinformconsumersandhealthcareworkersabouttheexistenceofLTOAU,highlightingitasanindependent,trustworthysourceofinformation.
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Access Initiatives – Raising Awareness ThecompromisedhealthoutcomesforAboriginalandTorresStraitIslanderpeoplesarewelldocumented.TheQualityUseofPathologyProgram(QUPP)enabledthreeprojects(Table11)toexplorewaystoimprovethehealthoutcomesforIndigenousAustraliansthroughraisingawarenessoftheneedtobecomeastakeholderintheirownhealthcare.ThiswasachievedthroughculturallyappropriateandclinicallyeffectivestrategiestoengageAboriginalAustraliansinunderstandingthebenefitsofactivelyparticipatingintheirownhealthcaretoachievepositivehealthoutcomes.Oneareaforfutureconsiderationnotedfromthisintegratedanalysisincluded: Furtherevaluationandextensionofthe‘FlipChart’conceptasnotedinthe
reportOptimisingHealthBenefitsforAboriginalPeoplewhotakeWarfarin[alt=“ThefollowingtableliststhethreeprojectnamesandgrantrecipientsundertheAccessInitiatives–RaisingAwarenesstheme”] Project Name Grant Recipient/s 1 OptimisingHealthBenefitsforAboriginal
PeoplewhotakeWarfarin(2009)RoyalAustralianCollegeofGeneralPractitioners(RACGP)
2 QualityAssuranceforAboriginalMedicalServices(QAAMS)(Current)
FlindersUniversity
3 QualityAssuranceforAboriginalMedicalServices(QAAMS)QualityAssuranceProgram(Current)
RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
Table11:ReportssummarisedforAccessInitiatives–RaisingAwareness
Optimising Health Benefits for Aboriginal People who take Warfarin (2009)
Description ThisprojectsoughttoexaminetheuseofanticoagulantsandInternationalNormalisedRatio(INR)testinginAboriginalandTorresStraitIslanderpeople,andtodevelopeducationalresourcesfortheiruse.LackofasharedunderstandingbetweendoctorsandpatientsofthebenefitsandrisksofWarfarintreatment(abrandofanticoagulantmedication),particularlyinvolvingpatientswithlimitedliteracyskills,hasbeendemonstratedtobeacontributingfactorinpoorINRcontrol.Thisprojecthasprogressedthroughtwostages:
1. Consultationthroughyarninggroups(focusgroups)withAboriginalandTorresStraitIslanderpatientstakinganti-coagulantmedication,andemergingfromthisconsultation;
2. Thedevelopmentofa‘FlipChart’whichisaneducationalresourcetobeusedasadiscussionaidbetweenahealthworkerandapatienttoprovideinformationabouttheneedforINRtestswhentakinganticoagulantmedication.
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Grant Recipient RoyalAustralianCollegeofGeneralPractitioners(RACGP)
Aims and Objectives
toidentifytheneedsofAboriginalpeoplewithrespecttoacommonandimportantpathologytest,namelytheINRbloodtest,performedforpatientstakingWarfarin
todesignculturallysensitiveinformationstrategiesthatimprovetheknowledgeofpathologytestinginrelationtoINRamongstagroupofAboriginalcommunities
topilotandevaluatetheinformationstrategies tomakerecommendationsaboutfutureinformationstrategiesforpathology
testsinAboriginalcommunities.These aims and objectives were achieved by this project.
Outcome
ThemostculturallyappropriateandclinicallyusefulinformationstrategytoimproveknowledgeofINRtestingwasthedevelopmentofpictorialhardcopymaterialsratherthananyelectronic/videoformat.Inthisprojecta‘FlipChart’wascreatedwhichwasa31pageA4sizedocumentstructuredtobeplacedonadeskorflatsurfaceinanA-Frameform.ThisenabledthepatienttoseetheimagesclearlydisplayedwhilethehealthprofessionaldiscussedparticularaspectsoftheimagethatrelatedtoINRtesting.
Finding
Theuseofyarninggroups/interviewswithpatientswasthemosteffectivemethodofidentifyingAboriginalpeople’sneedsinrelationtoINRtesting.
Recommendations 1. Thisproject’sdesignisarecommendedmodelforcross-organisationalwork
inAboriginalHealth.Themodel’skeyfeaturesincluded:o engagingwithAboriginalpeopleandcommunitiesinneeds
assessmentanddevelopmentofinterventions/educationalstrategieso partnershiparrangementsbetweenaleadorganisationandAboriginal
MedicalServices(AMSs),includingclarityregardingownershipanddisseminationofdatacollectedbyAMSs
o consultationwithclinicalstaffinAMSsthroughouttheimplementationoftheproject
o flexibilityintimesandoutcomesinresponsetoneedsofAMSsandpatients.
2. TheprojectdesignshouldbeextendedtootherpathologytestsofcriticalimportancetoAboriginalandTorresStraitIslanderpeopleinordertodevelopculturallyappropriatetoolstoassistpeopletoundertaketests.
3. TheprojectdesignshouldbeextendedtootherclinicalandhealthissuesinAboriginalHealth(notrestrictedtopathologytesting)inordertodevelopculturallyappropriateeducationalinterventions.
4. Astudyshouldbeundertakentotesttheeffectivenessofthe‘FlipChart’asaneducationalinterventiontoimprovemedicationandINRtestcompliancebyAboriginalandTorresStraitIslanderpatients.
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5. Thecontentofthe‘FlipChart’bedevelopedintoformatsthatcanbeeasilytakenhomebypatientsandtheirfamiliestoreinforcethemessagesfromthe‘FlipChart’discussedintheconsultation.Aleafletorcomicbookappearstobethemostappropriateformat.
6. Canvassopportunitiestofund‘reminders’forAboriginalandTorresStraitIslanderpatientstotakeWarfarinandhaveINRtests.Therangeofappropriate‘reminders’identifiedintheyarninggroupphaseoftheprojectincludefridgemagnets,textmessagestomobilephones,calendarsetc.
Key Project Learnings
TherewasstrongsupportbytheAboriginalcommunitiesforthecontentofthe‘FlipChart’tobeproducedintheformofleafletsorbookletsforthepatientstotakehome.
Futureprojectsutilisingthesameprojectdesign/modelshouldconsiderincludingthefollowingamendments:
o gain‘in-principle’commitmenttotheprojectbyspecificAMSsduringthedevelopmentoftheproposalratherthanrecruitingAMSsafterfundinghasbeenreceived
o employadedicated‘projectmanager’(ideallyanIndigenousperson)intheleadagencywithminimalresponsibilitiesoutsidetheproject
o clarifythespecificHumanResearchEthicsCommitteesthatrequireapprovaloftheprojectduringtheplanningstages
o resourcingforincreasedtravel/face-to-facecontactbetweentheleadagencyandAMSs
o increasedresourcingforstaffingattheleadagencyo increasedtimeofimplementingtheprojectwhichrecognisesthat
flexibilityandtimeisneededtobuildstrongworkingrelationshipso clearerguidancetoAMSsatthebeginningoftheprojecttoensurean
appropriateclinicalstaffmemberis‘assigned’toworkontheprojecto clarifytheneed/purposeofanyReferenceorWorkingGroupduring
theproposalstageoftheproject.
Areas for Future QUPP Consideration
Furtherevaluationandextensionofthe‘FlipChart’concepttoincludeothermorbidities.
Quality Assurance for Aboriginal Medical Services (QAAMS) (Current)
Description TheQualityAssuranceforAboriginalMedicalServices(QAAMS)programsoughttoprovideculturallyappropriateandclinicallyeffectivediabetesmanagementthroughtheuseoftwo“pointofcare”pathologytests(PoCT):glycosylatedhaemoglobin(HbA1c)andurinealbumin/creatinineratio(ACR),atparticipatingAboriginalandTorresStraitIslanderhealthservicesacrossAustralia.Amanagementframeworkoftraining,technicalsupportandqualitymonitoring,andaprogramforAboriginalcommunityleadersensuredthatpathologytestingmetthequalityachievedinconventionalpathologylaboratories.Therewasan
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Australia-widenetworkofsites(150in2010-2011)forPoCTtoassistineffectivediabetesmanagementinIndigenouscommunities.
Grant Recipient FlindersUniversity
Aims and Objectives
toestablishandmaintainaQAAMSProgramManagementGroup(QPMG)toco-ordinateandcontroltheconductoftheProject
toprovidescientific,technicalandclinicalsupportandon-goingscientificreviewoftheProject
toprovidecomprehensiveeducation,trainingandon-goingsupportfortheProject
todevelopmechanismstofosterandencouragegreaterAboriginalleadershipandexpertisewithintheProject
toincreasetheparticipationrateofAboriginalMedicalServices(AMSs)andAboriginalCommunityControlledHealthServices(ACCHSs)intheProgram
tooverseethemaintenanceoftheinternalqualitycontrolandexternalqualityassuranceprocesses.
These aims and objectives were achieved by this project.
Outcomes
ThenumberofservicesenrolledintheQAAMSProgramforHbA1candACRincreasedby78%(from60to107)to146%(from37to91)duringthecontractperiodof2006to2009.Tworecruitmentdrivesresultedinthecapof100servicesparticipatingintheprogrambeingexceededwhichnecessitatedacontractvariation.
AtelephonehotlinesupportservicewassetupandmannedbyaqualifiedscientistfromtheFlindersUniversityCommunityPoint-of-CareServices(CPS)unitduringbusinesshours(9amto5pm[CST]MondaytoFriday)acrossthecontractperiod.Totalcallsinwere1650andtotalcallsoutwere2185.
AquarterlyQAAMSnewsletteronissuesrelevanttotheQAAMSprogramwasroutinelyproducedandsenttoallparticipants,andlaterpostedontheQAAMSwebsite.
AQAAMSClinicalSupportOfficerwasappointedinearly2006. InformationwasprovidedtoAMSsandACCHSstoensuretheappropriate
useandunderstandingoftheMedicareRebate. TheQAAMSProgramManagerliaisedconsistentlywithBayer(nowSiemens
HealthCareDiagnostics)toensureparticipantsreceivedhighqualityservicesinrelationtotheprovisionofreagents,qualitycontrol(QC)andconsumables,andtechnicalsupportfortheDCA2000PoCTdevice.
TheFlindersCPSunitundertookamajorprogramofworkcalledtheQAAMS Diabetes Outcome StudymidwaythroughthecontractperiodtovalidatetheclinicaleffectivenessofQAAMSbycollectingandanalysingserialPoCTHbA1cresultsfrompatientswithestablisheddiabetesfromdifferentservicesparticipatinginQAAMS.Resultsfromthisanalysisshowed:
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o astatisticallysignificantreductioninmeanHbA1cof0.5%(from8.8%to8.3%)inthisgroupofpatientsoveramediantimeofobservationof29months(p<0.0001)
o thetimeperiodoverwhichPoCTwasmonitored(amedianof2.5years)indicatedthatimprovementsinmeanglycaemiccontroloccurredoverthelongtermandwerenotjustshort-termchanges
o aseparatemeansofanalysisshowedatrendtowardsimproveddiabeticcontrol;a12%increaseinthepercentageofpatientsachievingaHbA1c<8%,a7%reductioninthepercentageofpatientshavingaHbA1cbetween8%and10%,anda6%reductioninpatientswithpoorlycontrolleddiabetes.
ThereweresignificantadvancesandnewinitiativesinthedeliveryoftraininginPoCTforQAAMSparticipantsincluding:
o redevelopmentoftheQAAMSprimarytrainingresourceso developmentoftheQAAM’Swebsiteo neweducationinitiatives.
TheannualQAAMSWorkshopsincreasedtheirattendanceratesbetween2001and2008.
TheQAAMSLeadersGroupwasformedinMay2006wherebyonepersonofAboriginalorTorresStraitIslanderdescentwasselectedtorepresenteachStateorTerritory.TheydevelopedaMissionStatementforQAAMSandaTermsofReferencedocumentandplayedanintegralrolein:
o assessingtrainingresourcesfortheirculturalappropriatenesso assistingwithregionaltrainingvisitsbytheprimaryQAAMSTraining
Teamo deliveringtheannualQAAMSWorkshopthroughprogram
development,trainingassistance,deliveringspecificcoresessionsandmakingpresentations.
TheFlindersCPSunitandRoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)held29meetingstocollectivelyreviewthequalitycontrolandqualityassuranceresultsfromeachQAAMSsiteacrossthecontractperiod.
TheQAAMSManagementTeampublishedpapersaboutQAAMSintwopeer-reviewedpapers,andtheProgramManagerdeliveredinvitedlecturesontheQAAMSProgramatanumberofconferences/meetings.
Findings
Face-to-facetrainingandcompetencyassessmentthroughon-sitevisitstoindividualservicesorregionalworkshopswerecrucialcoreactivities.
Thelatterdevelopmentofsupportingon-lineweb-streamedtrainingvideoandcompetencyprocessesmeantmoredeviceoperatorscouldbetrainedthroughthismedium.Thiswasausefuladjunctfortraining,butwasnotintendedtoreplaceface-to-facetrainingwhichwasthemosteffectivemeansofdeliveringtrainingfordeviceoperatorsintheQAAMSProgram.
Recommendations 1. TheQAAMSProgramshouldembracetheopportunitytoincludenewPoCT
devicesastheyentertheAustralianmarket,providedtheymeetanalyticalgoalsandaresafeforpatientcare.Thismayinvolvenewchallengesto
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developtrainingandqualitymanagementprocessesthatcansupportthesenewdevices.
2. TheQAAMSManagementteamshouldfurtherengagetheQAAMSLeaderstoassistthescientificteaminestablishingcontactwithandrectifyingtheissuescausingpoorparticipationinQCtestingregimes.
Key Project Learnings
TheconstantchangeofhealthservicepersonnelinthelocationsmadethecontinuityofahighqualityPoCTserviceandmaintenanceoftrainingsupportdifficulttosustain.Theintroductionofweb-basedtrainingavailable24hrsaday7daysaweek,andtrainingDVDs,addressedthisissuetosomeextent,butthefundamentalissueofstaffretentioninruralandremoteAustraliawillremainapermanentissueforQAAMS.
HighstaffturnoverisalsoassociatedwiththemaintenanceofregularQCtestingregimens.
DatacollectionfortheDiabetesOutcomeStudywaslabourintensiveandnotstreamlineddespitetheeasy-to-followtemplatesandprocessesdesignedandimplementedtoassistthisprocess.Processesareinplacetoaddressthisissue.
Follow on Initiatives and Projects
SpecificfundingwasprovidedbytheCommonwealthGovernmentinthe2009Budgetforfouryears.ThesuccessoftheQAAMSprogramalsoledtoFlindersUniversityInternationalCentrebeingabletousetheQAAMSmodeltoassistinthedevelopmentof“pointofcare”pathologytestingprogramsinothercountrieswhichcurrentlyincludeCanada,SouthAfrica,ThailandandNewZealand.
Areas for Future Consideration
FurtherfundingforQAAMSwillbeconsideredunderthenewChronicDiseasePreventionandServiceImprovementFund.
Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current)
Description ThisprojectsoughttoprovideandmanagetheexternalqualityassurancecomponentoftheQualityAssuranceforAboriginalMedicalServices(QAAMS)Program,andassistintheprovisionoftraining,technicalsupportandqualitymanagementtoparticipatingAboriginalandTorresStraitIslanderhealthservicesacrossAustralia.ThisreportfocusesonCycle20whichranfrom30January2009to30June2009,anditsassociatedQAAMSactivities.
Grant Recipient RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)
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Outcomes
Therewere99enrolmentsforcycle20comprisingof96enrolmentsforglycosylatedhaemoglobin(HbA1c)and78enrolmentsforurinealbumin/creatinineratio(ACR).
InterimReportsandSupervisor’sReportswereprintedmonthlyassoonaspossibleaftertheclosingdate.
TheRCPAQAPandQAAMSmanagementmetmonthlytoreviewparticipation,qualitycontrol(QC)resultsandqualityassurance(QA)resultsanddecideifanyactionwasrequired.
Thetelephonehotlinesupportserviceiscontinuingtobeusedbyparticipants.
TheRCPAQAPcontributedtwonewslettersinthisreportingperiod.
Findings
Theparticipationrateof69%forHbA1cand64%forurineACRisanimprovementfromcycle19butstilllessthaninpreviousyears.TheAboriginalMedicalService(AMS)iscontactediftheyarenotparticipating.
ThepercentageofacceptableresultsforHbA1candurineACRremainedhighincycle20.
Key Project Learnings
StaffandtrainingarethemainissuesfortheQAAMS’QualityAssuranceProgram.
Itisachallengeforallparticipantstoreturnresultsbytheduedate.AprocesshasbeenputintoplacetoalertparticipantstotheconsequencesofnotsubmittingQCandQAresults.
Follow on Initiatives and Projects
SpecificfundingwasprovidedbytheCommonwealthinthe2009Budgetforfouryears.
Areas for Future Consideration
FurtherfundingforQAAMSwillbeconsideredunderthenewChronicDiseasePreventionandServiceImprovementFund.
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Communication Strategy and Stakeholder Engagement TheQualityUseofPathologyProgram(QUPP)soughttoengagestakeholdersinpathologythroughfourworkshops(Table12)toscopeoutissuesrelatingtothequalityuseofpathology.Theseworkshopsidentifiedanumberofissuesrelatingtostakeholderswithintheindustry,withtheQualityUseofPathologyCommittee(QUPC)seekingtoincreasetheirengagementwithconsumersduringthelatterworkshops.Commonissuesthatemergedduringtheseworkshopsincluded: workforcesafetyandquality,especiallyforAnatomicalPathologists recruitingandretainingaqualitypathologyworkforce lackofclearguidelinesaroundpathologyrequestingandreporting concernsabouteHealth increasedconsumerempowermentandengagement qualityassuranceissues.Theseworkshopsproducedmanyrecommendationsaboutthewayforwardinpathology,whilethisintegratedanalysiscapturedthefollowingareasforfutureconsideration: Emphasisshouldbeplacedonproducingguidelines(perhapsincorporating
patientpathways)allowinginformedchoicestobemadebyconsumersratherthanondifficulttodevelopandadministerregulation.
Reviewthepathologytestrequestformsforrelevancetothecurrentprovider/requester/consumerclimate.
Exploreoptionstodevelopguidelines/testingpathways,especiallyforhealthchecks,obesity,commonmulti-morbiditycombinationsandhypertension.
Exploreoptionstotargetrequestersatcriticaleducationandtrainingpoints. Exploretheissueofpathologytrainingandspecialtyopportunitiesfor
AboriginalandTorresStraitIslandermedicalgraduates. Explorethepossibilityofdevelopingguidelinesonsafepathologist
workloads.[alt=“ThefollowingtableliststhefourprojectnamesandgrantrecipientsundertheCommunicationStrategyandStakeholderEngagementtheme”] Project Name Grant Recipient/s 1 ReportfromtheNationalWorkshoponSafetyand
QualityinPathology(2007)MichaelLeggandAssociates
2 TheSecondNationalWorkshoponSafetyandQualityinPathology(2008)
MichaelLeggandAssociates
3 BestPracticeinPathologyRequestingandReportingWorkshop(2009)
ApisGroupPtyLtd
4 PathologyWorkforceWorkshop(2011) URBISTable12:ProjectssummarisedforCommunicationStrategyandStakeholderEngagement
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Report from the National Workshop on Safety and Quality in Pathology (2007)
Description Thisone-dayworkshopon28November2007broughttogetherkeystakeholdersfromthepathologyprofessionandindustry.TheyidentifiedanumberofkeythemesforfutureQualityUseofPathology(QUPP)investment,includingastrongconcernaboutthefuturesafetyandqualityofpathologyasaconsequenceofcurrentworkforceshortages.Stakeholdersrepresentedincluded: RoyalCollegeofPathologistsofAustralasia(RCPA) RCPAQualityAssuranceProgramsPtyLtd(RCPAQAP) AustralianAssociationofPathologyPractices(AAPP NationalCoalitionofPublicPathology(NCOPP) ConsumersHealthForumofAustralia(CHF) NationalE-HealthTransitionAuthority(NEHTA) AustralianCommissionofSafetyandQualityinHealthCare AustralasianAssociationofClinicalBiochemists(AACB) HealthInformaticsSocietyofAustralia(HISA) NationalAssociationofTestingAuthorities(NATA) ACTDivisionofGeneralPractice CancerInstituteofNSW UniversityofSydney(GPStatisticsandClassificationCentre) MedicalIndustryAssociationofAustralia
Grant Recipient MichaelLeggandAssociates
Aims and Objectives
tofocusonthefullspectrumofpathology-relatedqualityissuesfrom‘decisiontorequestaservice’through‘conductofthetesting’to‘useoftestresultsinpatientmanagement’
toreflectoncurrentplansandrecentpathologyinitiativesinpatientsafetyandquality
toidentifyanygapsthatneedaddressingandscanthehorizonforfutureissues
toproducearangeofoptionstoguidefuturedevelopmentactivityinthisareacontributingtostrategicplanningforboththeshortandmediumterm
tosuggesthowidentifiedconceptsorinitiativesshouldberankedandprioritiesforfutureattentionbytherelevantbodies.
These aims and objectives were achieved by this workshop.
Outcomes
TheWorkshopparticipantsidentifiedissuestheythoughtwouldbeimportantinrelationtosafetyandqualityintheprovisionofpathologyservicesforthenextthreeyears.Theissuesidentifiedinorderofprioritywere:1. workforce(127points)
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2. smartrequesting(87points)3. positiveidentification(63points)4. testingoutsideofthecurrentqualityframework(46points)5. smartreporting(44points)6. multidisciplinarycare(25points)7. clinicalaudit(14points).
AConsensusStatementonworkforcesafetyandqualityinpathologywasdevelopedaftertheWorkshopbasedonagreementaboutthepathologyworkforceissueidentifiedduringtheWorkshop.Itcouldbeusedtoescalatetheissueandadvocateforremedy.TheConsensusStatementdevelopedis:Thereisacritical threat to the safety and qualityoftheworld-classpathologysystemthatAustraliacurrentlyhas;itisworkforceshortages.Theproblemextendstotheentirerangeofthoseinvolvedinprovidingpathologyservicesbutinparticularitaffects
a. Pathologists and b. Laboratory Scientists/Techniciansand Health Informaticians.
Theshortageofqualifiedstaffisalready having an impactonthewaythatpathologypracticesareorganisingthemselvesandthishasbeenevidentforatleastthelastthreeyears.Theproblemisnot because of inefficienciesbecauseAustralianlaboratoriesareamongthemostefficientintheworld.Therearetoo few trainees in the system to meet current needsletalonetodealwiththeageingworkforce.Therearewillingtraineesandtrainersfrombothpublicandprivatepracticesbutthereisinsufficientstateandterritorygovernmentfunding for this education. Theworkforce shortage will only be exacerbatedbytheincreasedrelianceonpathologyinthepracticeofmodernmedicineandtheburgeoningdiseaseburdenofanageingpopulation.Actionbythevariouspartiesmustbetakennowtoavoidseriousconsequencestohealthoutcomes.
Finding
ThecurrentqualityframeworkinpathologylaboratoriesmeansmostriskandopportunityforimprovementisinthenodesofthePathologyRequestTestReportCycleinthepre-andpost-analyticalstages,ratherthanattheanalyticalstage.
Recommendations 1. Consideroptionsforactiontoaddressidentifiedprioritiesthroughthe
QualityUseofPathologyCommittee(QUPC)andNationalPathologyAccreditationAdvisoryCouncil(NPAAC).
2. Considerreconveningintwoyearstoevaluateprogressandrevisetheplan.
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Follow on Initiatives and Projects
TheSecondNationalWorkshoponSafetyandQualityinPathology
The Second National Workshop on Safety and Quality in Pathology (2008)
Description Thisone-dayworkshopon6November2008wasthesecondplatformtohighlightanddiscussQualityUseofPathologyProgram(QUPP)initiatives.ItshowcasedcurrentandrecentQUPP-fundedinitiativesandfurtherworktodateonprioritiesidentifiedintheReportfromtheNationalWorkshoponSafetyandQualityinPathologyonpage172.ThissecondWorkshopalsosoughttomoreexplicitlyengagewithrequestersandconsumers.Stakeholdersrepresentedincluded: RoyalCollegeofPathologistsofAustralasia(RCPA) RCPAQualityAssuranceProgramsPtyLtd(RCPAQAP) AustralianAssociationofPathologyPractices(AAPP) NationalCoalitionofPublicPathology(NCOPP) ConsumersHealthForumofAustralia(CHF) NationalE-HealthTransitionAuthority(NEHTA) RoyalAustralianCollegeofGeneralPractitioners(RACGP) AustralasianAssociationofClinicalBiochemists(AACB) HumanGeneticsSocietyofAustralasia(HGSA) HealthInformaticsSocietyofAustralia(HISA) NationalAssociationofTestingAuthorities(NATA) ACTDivisionofGeneralPractice CancerInstituteofNSW UniversityofSydney(GPStatisticsandClassificationCentre) MedicalIndustryAssociationofAustralia
Grant Recipient MichaelLeggandAssociates
Aims and Objectives
toprovideanupdatetostakeholdersontheprogressmadeinthepriorityareassincetheinitialWorkshop,anddiscussfutureproposedwork
toidentifyanygapsthatneedaddressing tofurtherscanthehorizonforfutureissuestobeaddressed.These aims and objectives were achieved by this workshop.
Outcomes
Twointeractivesessionswereheldduringtheworkshop. Thefirstwastotestthe‘QualityFramework’Mapprovidedinthepre-
readingforcompletenessofthelistbycategoryoftheorganisationsandtheirproductsthatareinvolvedinthenationalpathologyqualityframework(outsideoftheactuallaboratories),andsuggestionswerecollectedwhichwillbeusedtoexpandthisreport.
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Thesecondsessionwasaninvitedopendiscussionontheworkbeingdonetohelpandprotectconsumersusingpathologytestingundertheircontrol(asopposedtothoserequestedbymedicalpractitioners).
Recommendations 1. Emphasisshouldbeplacedonproducingguidelines(perhapsincorporating
patientpathways)allowinginformedchoicestobemadebyconsumersratherthanondifficulttodevelopandadministerregulation.
2. ContinuetodevelopstrategiestoaddressworkforceshortagesinpathologyandreconveneagroupforthatpurposeinMarch2009.
Follow on Initiatives and Projects
BestPracticeinPathologyRequestingandReportingWorkshop.
Areas for Future Consideration
AsperrecommendationNo.1above.
Best Practice in Pathology Requesting and Reporting Workshop (2009)
Description Thisone-dayworkshopon9December2009soughttopromotecollaborative,evidence-basedpathologyrequestingandreportingstrategies.Itincludedpresentationsandsomediscussioninrespecttothelateststudiesensuringpatientsafetyandqualityinpathologycommunications,emergingissuesandprioritiesandopportunitiesforfuturecollaborationofagreedpriorities.Stakeholdersrepresentedincluded: RoyalCollegeofPathologistsofAustralasia(RCPA) QualityUseofPathologyCommittee(QUPC) NationalPathologyAccreditationAdvisoryCouncil(NPAAC) NationalPrescribingService(NPS) AustralianAssociationofPathologyPractices(AAPP) AustralianGeneralPracticeNetwork RoyalAustralianCollegeofGeneralPractitioners(RACGP) CancerAustralia NationalCoalitionofPublicPathology(NCOPP) ConfederationofPostGraduateMedicalEducationCouncil NSWInstituteofMedicalEducationandTraining NationalInstituteofClinicalStudies RoyalAustralianCollegeofSurgeons(RACS) RuralDoctorsAssociation HealthInformaticsSocietyofAustralia ConsumersHealthForumofAustralia(CHF) NationaleHealthTransmissionAuthority(NEHTA) RoyalAustralasianCollegeofPhysicians(RACP) AustralianMedicalAssociation(AMA) CommitteeofDeansofAustralianMedicalSchools MedicalStudentsAssociation
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DepartmentofHealthandAgeing(DOHA).
Grant Recipient ApisGroupPtyLtd
Objective
toexploreandpromotecollaborative,evidence-basedpathologyrequestingandreportingstrategies.
This objective was achieved by this workshop.
Outcomes
Abroadrangeoftopicswerepresentedanddiscussedcoveringthelateststudies,ensuringpatientsafetyandqualityinpathologycommunications,emergingissuesandprioritiesandopportunitiesforfuturecollaborationonagreedpriorities.
APlenarySessionfocusedonpriorityareasforfuturedevelopmentandcollaborationinpathologyrequestingandreporting.
Findings
Whereclearclinicalpathways/guidelinesexistandarewellknown,pathologyrequestingpatternslargelyappeartomirrorguidelines.Problemstendtobefoundwheretherearenotclear,agreedguidelinesand/orclinicianshavetojugglecompetingandpossiblynon-alignedguidanceforseveralconditions.
Adheringtopatientandsampleidentificationandcollectionprotocolsexternaltopathologyprovidersisoneevidence-basedmethodofpreventingharmtopatients.
Recommendations Theworkshopidentifiedpriorityareasforfurtherdevelopmentandexplorationincluding:1. EnsuringeHealthsystemcapacityprovidesaneffectiveplatformfor
transferringclinicalinformationandresultsbetweenrequestersandpathologyproviders.
2. Increasingthefocusontheformatandcontentofpathologytestrequestformsandthepossibleinclusionofmoreclinicalinformationtodrawonpathologists’expertiseregardingsmartrequesting.
3. Targetingrequestertrainingatcriticaleducationandtrainingpointse.g.postgraduationyearone(PGY1)andPGY2curriculumandgeneralpractice(GP)registrartrainingprograms.
4. Developingclinicalpracticeguidelinesontestrequestingforhealthchecksandthemanagementofobesity,commonmulti-morbiditycombinationsanduncomplicatedhypertension.
5. Focusingonconsumerempowermentandengagementthrough:a. bettereducationandtrainingofclinicianstosupportthisb. improvedaccesstoinformationincludingawarenessofrisksand
dangersofunnecessarytestingc. bettercommunication(readabilityofpathologyreports,needfor
consumer-friendlylanguage,culturalsensitivity)d. guidelinesformonitoring/maintenanceincludingself-management.
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6. Exploringtheneedforfurtherresearchontherationalesforpathologyorderingacrossvarioussettingsandprovidertypes.
7. Promotingthedevelopmentofmorecomprehensibleandusefulreportingofpathologytestresults.
8. Exploringclinicalgovernanceissuesaroundaccountabilityandtransparencyofpathologyrequestandresulttransactions.
9. Exploringthecapacityforrequesterstoordertestsaccordingtopatientcircumstances.
10. Improvingmechanismstomonitortestingalgorithmsand/ormanagedundersharedcarearrangements(e.g.anaemia).
11. Exploringtheneedtocollateandanalysepublicsectorbestpracticerequestingstrategiesforpossibleapplicationtothefee-for-servicetestingmodel.
Areas for Future Consideration
Reviewthepathologytestrequestformsforrelevancetothecurrentprovider/requester/consumerclimate.
Exploreoptionstodevelopguidelines/testingpathways,especiallyforhealthchecks,obesity,andcommonmulti-morbiditycombinationsandhypertension.
Exploreoptionstotargetrequestersatcriticaleducationandtrainingpoints.
Pathology Workforce Workshop (2011)
Description Thisone-dayworkshopon22June2011soughttoinformstakeholdersofrecentresearchanddevelopmentsrelatingtothepathologyworkforce,andtoprovideanopportunityfordiscussionofkeyissuesforthespecialistandscientificworkforce.Bothmedicalandscientificprofessionalsattendedwithkeyissuesraisedincludinglimitedcareeropportunities,increaseddemandsontheworkforceandaforecastdecreaseinbothspecialistandscientificworkforcenumbers.TheAustralianAssociationofPathologyPractices(AAPP)wasnotrepresentedattheworkshop,andaskedthattheirdecisionnottoattendbenoted.(ThenumberofdelegatesavailabletoattendthisworkshopwassubstantiallyreducedatshortnoticeduetotheclosureofSydneyAirportrelatedtoanashcloudfromavolcaniceruptioninChile.)
Grant Recipient URBIS
Aims
toprovidearepresentativeforumfordiscussionofpathologyworkforceissues
toconsiderthefindingsofresearchrelatedtothepathologyworkforce toidentifyinformationgapsrequiringfurtherresearchorinvestigation.
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Objective
tostimulatediscussionanddebateregardingcurrentandprojectedworkforcechallengesandsolutions.
These aims and objective were achieved by this workshop.
Findings Workforce Issues Thereisadecliningproportionofworkingagepopulationandanageing
populationwithincreasingdemandsforpathologyservices. Thereareculturalchangesacrossgenerationswhicharepredictedtoimpact
onworkforcechoicesinthefuture,withmanyyoungerpeoplechoosinglifestylechoicesovercareeradvancement.
Thecareerframeworkislesswelldefinedforthescientificworkforcethanitisforthespecialistpathologistworkforce.
Influencesonthefuturepathologyworkforceidentifiedinclude:o theneedformoreflexibleworkplaceenvironmentso increasingandchangingdemandsfortechnologieso thegrowingmovewithinAustraliatowardsnationallyconsistent
accreditationandstandards. Themainchallengesidentifiedbyemployersare:
o shortageofskilledlabouro highstaffturnovero poorMedicarerebateso thehighcostofwages/remunerationo difficultiesstaffingout-of-hoursshifts.
Keyissuesforemployeeswere:o thedesirefornewchallengeso limitedcareeropportunities,particularlyforthescientificworkforceo insufficientrewards,particularlyforthescientificworkforceo stress/burnouto adesireforimprovedwork-lifebalance.
Thecurrentworkforcelevels,whichhaveincreased(particularlyinruralareas)forAnatomicalPathologists,representathreattothehealthandwellbeingofpathologists,andonthequalityandsafetyofpathologyservices.
Thereneedstoberecognitionthatparticipatingpathologistsperformotherdutiesinadditiontoreportingonpatient-relatedactivities.
Segmentingtheworkforceindiscreteroleswithdifferenttrainingpathways,accreditationrequirementsandcareerpathways,andwithdifferentindustrialarrangementsacrossStates/Territories,hasnotbeenconducivetodevelopingclearandconsistentcareerframeworks.
Issuesrelatingtothespecialistworkforceinclude:o aperceivedneedforflexibilityacrosspathologysub-disciplineso workforceshortagesandtheproposalforincreasedrecruitmentof
medicalgraduatesintopathology,includingthecreationofmoretrainingpositions
o thecreationofmorespecialistpathologistpositionstocopewiththeincreaseinthedemandforservices
o increasingservicedemandandtheimpactofworkloadpressuresonpathologists’healthandwellbeing,aswellasqualityandsafety
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o changingtechnologiesandtheproposalforenhancedtrainingincludingsupportfortrainingwhilestillworking
o flexibleworkpracticesandthedevelopmentofacareerframeworkwhichcouldprovidenewoptionsforpathologiststomoveintoandoutofpathologyspecialtiesoveralifetime’scareer.
Thereisacriticalneedtorecruitandretainseniorscientists. ThereisnodedicatedpathwayforAboriginalandTorresStraitIslander
medicalgraduates,whichmaybeaddressedinthefuture.Research Findings Thereisalargeamountofdatatosupportactiontoaddresskeyworkforce
challengesandnopressingneedfornewresearch. Theincreaseinthedemandandcomplexityofpathologyserviceswillrequire
innovative,long-termplanninginordertorespondtothechangingtechnologicalenvironmentandensurethecapacityoftheworkforcetoadapttochangingmarketneeds.
Thenumberofpathologytraineeshasincreasedfrom406in2008to474in2010.
Theincreasingdrivetowardssub-specialisationmayrequireevenmorepathologiststhanotherwisetoprovideforbothgeneralistandsub-specialtypathologydemands.
General Findings ThePathologyAssociationsCouncil(PAC)CompetencyBasedStandards
(CBS)frameworkforMedicalScientistsprovidesastructureforcreatingascopeofpracticeanddevelopingacareerpathwaywhichcouldbeformalisedinindustrialrewardstructures.
Newtechnologies,suchasdecisionsupportandpointofcaretesting,willrequireaflexibleandresponsiveworkforcetoadapttochangingworkpracticesandservicedemands.Insomecasestechnologymayincreaseworkloads,whileitmaydecreaseworkloadsandincreasecapacityforothertasks.
Itisimportantforthepathologysectorandgovernmenttoworktogethertoensuretheworkforceisabletomeetthedemandsforfutureservices.
Thereisatrendtowardsconcentratingservicesinurbanareaswhichisreducingtheopportunitiesforruralcareers.Innovativepackagingorincentivesandprofessionalopportunities,aswellasstrategiessuchascreatinggeneralistpositionsforanatomicalpathologytraineesbasedinregionalorrurallocations,couldencouragemorepractitionerstoworkinruralareas.
Recommendations 1. Abettertrainingandcareerframeworkforseniorscientistsshouldbe
exploredwhichalsoconsideredthedrivetosub-specialisation,andthepotentialforprofessionals(includingpathologists)tomoveinoroutofsub-specialtiesoverthecourseoftheircareer.
2. Exploreoptionstopromotethevalueofpathologyservicestothebroaderhealthsystemandwithinuniversitiestogainthecooperationofthoseinapositiontoassistwithaddressingrecruitment,trainingandworkloadneeds.
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3. Existingstudiesanddatacouldbefurtherminedandanannualsurveyonemploymentanddatatrendswouldbeuseful.
4. Exploretheoptionofimplementingcomprehensivenationalworkforceplanning.
5. Qualitymeasuresforanatomicalpathologyneedtobegivenmorepriority.6. Possiblefutureactionstorecruitandretainseniorscientistsinclude:
a. reviewcurrentindustrialarrangementsb. undertakealabourmarketanalysisc. supportstructuredtrainingd. provideaclearandstructuredcareerpathwaye. nationallyconsistentcompetency-basedstandards,roledefinitionand
assessmentprocessesf. remunerationrelativetoqualificationsandspecialisationg. supporttoundertakeaprofessionalfellowship.
7. Acareerframework,supportedbygreaterflexibilitywithintheworkplace,isessentialtoensurethefuturepathologyworkforcewasabletomeetthedemandsforservices.Thismayneedtobecoordinatedwithundergraduateandpostgraduatetraining,andofferoptionsforongoingprofessionaldevelopmentsupportedwhileretainingspecialistsinemployment.
8. Exploreoneaccuratemethodtocollectworkforcedataforboththespecialistandscientificworkforce.
9. Forecastthenumberofpathologyspecialistsrequiredinthefuturetoensurethereiscapacitywithinthetrainingpipelinetoaccommodateanincreasednumberofpathologytrainees,includingdefiningafull-timeworkload.
10. Identifythegapsintheavailabledataonthedemandforpathologyservices.11. Developguidelinesonsafepathologistworkloads.12. Profiletheworkforcedifferencesbetweenprivateandpubliclaboratories.13. Comparetheattritionratestothoseinotherprofessionstoassesstheextent
oftheproblem.
Follow on Initiatives and Projects
FurtherpossibleworkthroughtheWorkforceAdvisoryCommitteeunderthePathologyFundingAgreement.
Areas for Future Consideration
ExploretheissueofpathologytrainingandspecialtyopportunitiesforAboriginalandTorresStraitIslandermedicalgraduates.
Explorethepossibilityofguidelinesonsafepathologistworkloads.
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Appendix A – Report Summaries Relevant to Different Themes TheQualityUseofPathology(QUPP)reportsummariesincorporateprinciplesandstrategiesrelevanttoadditionalchapterthemeswhicharehighlightedinthetablebelow. Project
Name Chapter Theme
1 EvaluationoftheImpactonPathologyPracticeoftheManualofUseandInterpretationofPathologyTests(2001)
PathologyRequestingandReporting–RequesterandConsumerFocusWorkforceCapacityandCompetence
2 AnHistoricalAnalysisofPathologyOrderingbyGeneralPractitionersbetweenApril1998andMarch2001fromtheBetteringtheEvaluationandCareofHealth(BEACH)Program(2002)
PathologyRequestingandReporting–RequesterandConsumerFocus
3 AProjecttoExaminetheUtilisationofPathologyTestsintheInvestigationofTirednessinGeneralPractice(2002)
PathologyRequestingandReporting–RequesterandConsumerFocus
4 AnalysisofCurrentPracticesinRelationtotheTeachingofPathology
WorkforceCapacityandCompetence
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(LaboratoryMedicine)(2003)
5 AnalysisofCurrentLaboratoryMedicine(Pathology)TeachingPracticeinPrevocationalandGeneralPractitionerVocationalTraining(2003)
WorkforceCapacityandCompetence
6 AMechanismfortheDevelopment,ImplementationandEvaluationofEvidence-Based,Best-PracticeClinicalGuidelinestoFacilitateQualityUseofPathologyTests(2003)
PathologyRequestingandReporting–RequesterandConsumerFocus
7 RevisionofManualofUseandInterpretationofPathologyTests(2004)
eHealthCapabilityPathologyRequestingandReporting–RequesterandConsumerFocus
8 AcademicDetailingSupportingBetterOutcomesfromDiagnosticTechnologies(2004)
PathologyRequestingandReporting–RequesterandConsumerFocus
9 CommonSensePathology(2006)
PathologyRequestingandReporting–RequesterandConsumerFocus
10
ImprovedPathologyReporting,EducationandPractice(IPREP)forColorectalCancer(2009)
PathologyRequestingandReporting–RequesterandConsumerFocus
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11
Evidence-Based,Best-PracticePreventionofBloodBorneVirusTransmissioninHealthCareSettingsProgram(PBBV)(2009)
RiskMinimisationPathologyRequestingandReporting–RequesterandConsumerFocusCommunicationStrategyandStakeholderEngagement
12
StructuredPathologyReportingStandardsforCancer(2009)
RiskMinimisationeHealthCapability
13
Evidence-PracticeGapinGPPathologyTestOrdering:AComparisonofBEACHPathologyDataandRecommendedTesting(2009)
PathologyRequestingandReporting–RequesterandConsumerFocus
14
RCPAManualTransformationProject(2010)
eHealthCapabilityPathologyRequestingandReporting–RequesterandConsumerFocus
15
CommonSensePathologyPublicationSeries(2011)
PathologyRequestingandReporting–RequesterandConsumerFocusCommunicationStrategyandStakeholderEngagement
16
PromotingandExpandingStructuredPathologyReportingofCancer(Stage2)(Current)
PathologyRequestingandReporting–RequesterandConsumerFocus
17
RCPA–QualityAssuranceProgramsKeyIndicatorProject(2004)
WorkforceCapacityandCompetence
18
PilotLaboratoryAssessmentandPeerReviewMechanismforPathologyKeyPerformanceIndicators(2007)
WorkforceCapacityandCompetence
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19
KeyIncidentMonitoring&ManagementSystems(Current)
WorkforceCapacityandCompetence
20
PerformanceMonitoringofExternalQualityAssurance(Current)
WorkforceCapacityandCompetence
21
NATAFileAudit–RiskAnalysisofAssessmentNonConformancesIdentifiedinPathologyLaboratoryAssessmentAccreditation(Current)
WorkforceCapacityandCompetence
22
VirtualMicroscope(2005)
WorkforceCapacityandCompetence
23
DevelopmentofaQualityAssuranceModuleforHumanPapillomaVirusTesting(2008)
RiskMinimisationWorkforceCapacityandCompetence
24
PreparingforGenomicMedicine:NationalAuditandDevelopmentofaBestPracticeApproach(2009)
RiskMinimisationPathologyRequestingandReporting–RequesterandConsumerFocus
25
HighResolutionScanningMicroscopyforQualityAssuranceandEducationalApplications(2009)
WorkforceCapacityandCompetence
26
Policies,ProceduresandGuidelinesforPoint-of-CareTesting(2011)
WorkforceCapacityandCompetence
2 Establishment RiskMinimisation
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7 ofaMolecularGeneticsQualityAssuranceProgram(Current)
28
MAWSON–AnOnlineRepositoryofGeneticDatatoAidReportingofMedicalGeneticTests(Current)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved
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Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:10. PromotingEvidence-BasedPractice11. RiskMinimisation12. QualityAssuranceandCapacity–NewTechnology13. eHealthCapability14. PathologyRequestingandReporting–RequesterandConsumerFocus15. WorkforceCapacityandCompetence16. ConsumerFocusandInformationStrategies17. AccessInitiatives–RaisingAwareness18. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:4. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
5. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
6. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:4. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
5. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
6. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
10. PromotingEvidence-BasedPractice11. RiskMinimisation12. QualityAssuranceandCapacity–NewTechnology13. eHealthCapability14. PathologyRequestingandReporting–RequesterandConsumerFocus
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15. WorkforceCapacityandCompetence16. ConsumerFocusandInformationStrategies17. AccessInitiatives–RaisingAwareness18. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:19. PromotingEvidence-BasedPractice20. RiskMinimisation21. QualityAssuranceandCapacity–NewTechnology22. eHealthCapability23. PathologyRequestingandReporting–RequesterandConsumerFocus24. WorkforceCapacityandCompetence25. ConsumerFocusandInformationStrategies26. AccessInitiatives–RaisingAwareness27. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:7. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
8. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
9. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:7. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
8. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
9. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
19. PromotingEvidence-BasedPractice20. RiskMinimisation21. QualityAssuranceandCapacity–NewTechnology22. eHealthCapability23. PathologyRequestingandReporting–RequesterandConsumerFocus
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24. WorkforceCapacityandCompetence25. ConsumerFocusandInformationStrategies26. AccessInitiatives–RaisingAwareness27. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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29
PoCTTraining,Certification,SupportandSkillMaintenanceProgram(AustralianPoCTPractitionersNetwork–APPN)(Current)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:28. PromotingEvidence-BasedPractice29. RiskMinimisation30. QualityAssuranceandCapacity–NewTechnology31. eHealthCapability32. PathologyRequestingandReporting–RequesterandConsumerFocus33. WorkforceCapacityandCompetence34. ConsumerFocusandInformationStrategies35. AccessInitiatives–RaisingAwareness36. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:10. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
11. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
12. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:10. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
11. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
12. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
28. PromotingEvidence-BasedPractice29. RiskMinimisation30. QualityAssuranceandCapacity–NewTechnology31. eHealthCapability32. PathologyRequestingandReporting–RequesterandConsumerFocus
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33. WorkforceCapacityandCompetence34. ConsumerFocusandInformationStrategies35. AccessInitiatives–RaisingAwareness36. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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30
PathologyInformaticsWorkingParty(2003)
PathologyRequestingandReporting–RequesterandConsumerFocus
31
DevelopmentofonOn-lineMaintenanceSystemfortheAustralianPathologyRequestandResultCodeSets(2003)
PathologyRequestingandReporting–RequesterandConsumerFocus
32
PathologyandGeneralPracticeSoftwareIntegrationProject(PaGSIP)(2003)
PathologyRequestingandReporting–RequesterandConsumerFocus
33
ChainofInformationCustodyforthePathologyRequest-Test-ReportCycleinAustralia(GuidelinesforPathologyRequestersandPathologyProviders)(2004)
PathologyRequestingandReporting–RequesterandConsumerFocus
34
SupportingHL7forHealthInformaticsStandards(2004)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
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Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................
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Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final
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Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and
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toproduceadocumentthatwouldrecordthepastandpresentinvestmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:37. PromotingEvidence-BasedPractice38. RiskMinimisation39. QualityAssuranceandCapacity–NewTechnology40. eHealthCapability41. PathologyRequestingandReporting–RequesterandConsumerFocus42. WorkforceCapacityandCompetence43. ConsumerFocusandInformationStrategies44. AccessInitiatives–RaisingAwareness45. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowon
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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initiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
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Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:13. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
14. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentoftheirmedicaltraining.
15. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
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Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding
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(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.TheprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedbyDoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:13. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
14. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
15. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
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Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
37. PromotingEvidence-BasedPractice38. RiskMinimisation39. QualityAssuranceandCapacity–NewTechnology40. eHealthCapability41. PathologyRequestingandReporting–RequesterandConsumerFocus42. WorkforceCapacityandCompetence43. ConsumerFocusandInformationStrategies44. AccessInitiatives–RaisingAwareness45. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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35
AStudyoftheImpactoftheUseofGeneralPracticeComputerSystemsontheOrderingofPathology(2004)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
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Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................
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Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................
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The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.
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Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:46. PromotingEvidence-BasedPractice47. RiskMinimisation48. QualityAssuranceandCapacity–NewTechnology49. eHealthCapability50. PathologyRequestingandReporting–RequesterandConsumerFocus51. WorkforceCapacityandCompetence52. ConsumerFocusandInformationStrategies53. AccessInitiatives–RaisingAwareness54. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–Requesterand
17 9
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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ConsumerFocusPromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytesting
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process.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:16. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
17. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentoftheirmedicaltraining.
18. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists
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AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtowork
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withtheAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.TheprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedbyDoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:16. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
17. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
18. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
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presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
46. PromotingEvidence-BasedPractice47. RiskMinimisation48. QualityAssuranceandCapacity–NewTechnology49. eHealthCapability50. PathologyRequestingandReporting–RequesterandConsumerFocus51. WorkforceCapacityandCompetence52. ConsumerFocusandInformationStrategies53. AccessInitiatives–RaisingAwareness54. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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PathologyRequestingandReporting–RequesterandConsumerFocus
36
ApplicationofPathologyInformaticstoReportingofCritical/AbnormalResultsforImprovedRequester/ProviderCommunicationandImprovedPatientCare(2004)
PathologyRequestingandReporting–RequesterandConsumerFocus
37
PadlokOn-linePathologyOrderingSystem(2005)
RiskMinimisation
38
InformationExtractionfromNarrativePathologyReportsonMelanoma(2008)
RiskMinimisation
39
AutomaticCompilationofSynopticReportsfromNarrativePathologyReports(Stage2)(2010Submittedwiththetitle:ThePathologyReporter)
PathologyRequestingandReporting–RequesterandConsumerFocus
4 Automatic PathologyRequestingandReporting–RequesterandConsumerFocus
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0 PopulationofSynopticReportsfromNarrativePathologyReports(Stage3)(Current)
41
StandardisationofPathologyTerminologyandUnits(Current)
RiskMinimisation
42
GuidelinesforPatient/ConsumerAccesstoPathologyTestReports(2001)
ConsumerFocusandInformationStrategies
43
AUSLABRetestIntervalTrialProject(2003) Integrated Analysis of Quality Use of
Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
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Cognitus Pty Ltd Jane Carstens
Table of Contents
Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................
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Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
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Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:55. PromotingEvidence-BasedPractice56. RiskMinimisation57. QualityAssuranceandCapacity–NewTechnology58. eHealthCapability59. PathologyRequestingandReporting–RequesterandConsumerFocus60. WorkforceCapacityandCompetence61. ConsumerFocusandInformationStrategies62. AccessInitiatives–RaisingAwareness63. CommunicationStrategyandStakeholderEngagement.
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The number of reports within each theme is presented in Figure 1.
Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:19. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-
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collectedsamples.20. Educatingmedicalstudentsduringtheirtrainingandpost-graduate
yearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentoftheirmedicaltraining.
21. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission
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HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthand
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Ageing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.TheprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedbyDoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:19. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
20. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
21. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
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55. PromotingEvidence-BasedPractice56. RiskMinimisation57. QualityAssuranceandCapacity–NewTechnology58. eHealthCapability59. PathologyRequestingandReporting–RequesterandConsumerFocus60. WorkforceCapacityandCompetence61. ConsumerFocusandInformationStrategies62. AccessInitiatives–RaisingAwareness63. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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44
HomeMonitoringofWarfarinTherapyinChildrenusingtheCoaguchekTMPointofCareINRMonitor(2003)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
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Table of Contents
Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................
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Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:64. PromotingEvidence-BasedPractice65. RiskMinimisation66. QualityAssuranceandCapacity–NewTechnology67. eHealthCapability68. PathologyRequestingandReporting–RequesterandConsumerFocus69. WorkforceCapacityandCompetence70. ConsumerFocusandInformationStrategies71. AccessInitiatives–RaisingAwareness72. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:22. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
23. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
24. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:22. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
23. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
24. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
64. PromotingEvidence-BasedPractice65. RiskMinimisation66. QualityAssuranceandCapacity–NewTechnology67. eHealthCapability68. PathologyRequestingandReporting–RequesterandConsumerFocus
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69. WorkforceCapacityandCompetence70. ConsumerFocusandInformationStrategies71. AccessInitiatives–RaisingAwareness72. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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AUSLABRetestIntervalProject(2004) Integrated Analysis of Quality Use of
Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:73. PromotingEvidence-BasedPractice74. RiskMinimisation75. QualityAssuranceandCapacity–NewTechnology76. eHealthCapability77. PathologyRequestingandReporting–RequesterandConsumerFocus78. WorkforceCapacityandCompetence79. ConsumerFocusandInformationStrategies80. AccessInitiatives–RaisingAwareness81. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:25. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
26. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
27. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:25. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
26. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
27. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
73. PromotingEvidence-BasedPractice74. RiskMinimisation75. QualityAssuranceandCapacity–NewTechnology76. eHealthCapability77. PathologyRequestingandReporting–RequesterandConsumerFocus
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78. WorkforceCapacityandCompetence79. ConsumerFocusandInformationStrategies80. AccessInitiatives–RaisingAwareness81. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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46
FacilitatingBestPracticePathologyUtilisationbytheUseofHand-HeldDecisionSupportDevices(2004)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:82. PromotingEvidence-BasedPractice83. RiskMinimisation84. QualityAssuranceandCapacity–NewTechnology85. eHealthCapability86. PathologyRequestingandReporting–RequesterandConsumerFocus87. WorkforceCapacityandCompetence88. ConsumerFocusandInformationStrategies89. AccessInitiatives–RaisingAwareness90. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:28. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
29. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
30. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:28. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
29. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
30. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
82. PromotingEvidence-BasedPractice83. RiskMinimisation84. QualityAssuranceandCapacity–NewTechnology85. eHealthCapability86. PathologyRequestingandReporting–RequesterandConsumerFocus
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87. WorkforceCapacityandCompetence88. ConsumerFocusandInformationStrategies89. AccessInitiatives–RaisingAwareness90. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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47
ImprovingGPAccesstoandUseofRetrospectiveandCurrentPathologyDatatoIncreaseDetectionofEarlyDiabetes(IGTandIFG)inGeneralPractice(2005)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:91. PromotingEvidence-BasedPractice92. RiskMinimisation93. QualityAssuranceandCapacity–NewTechnology94. eHealthCapability95. PathologyRequestingandReporting–RequesterandConsumerFocus96. WorkforceCapacityandCompetence97. ConsumerFocusandInformationStrategies98. AccessInitiatives–RaisingAwareness99. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:31. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
32. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
33. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:31. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
32. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
33. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
91. PromotingEvidence-BasedPractice92. RiskMinimisation93. QualityAssuranceandCapacity–NewTechnology94. eHealthCapability95. PathologyRequestingandReporting–RequesterandConsumerFocus
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96. WorkforceCapacityandCompetence97. ConsumerFocusandInformationStrategies98. AccessInitiatives–RaisingAwareness99. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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48
QualityUseofPathologyServicesEducationProgram(2006)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:100. PromotingEvidence-BasedPractice101. RiskMinimisation102. QualityAssuranceandCapacity–NewTechnology103. eHealthCapability104. PathologyRequestingandReporting–RequesterandConsumer
Focus105. WorkforceCapacityandCompetence106. ConsumerFocusandInformationStrategies107. AccessInitiatives–RaisingAwareness108. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:34. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
35. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
36. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:34. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
35. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
36. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
100. PromotingEvidence-BasedPractice101. RiskMinimisation102. QualityAssuranceandCapacity–NewTechnology103. eHealthCapability104. PathologyRequestingandReporting–RequesterandConsumer
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Focus105. WorkforceCapacityandCompetence106. ConsumerFocusandInformationStrategies107. AccessInitiatives–RaisingAwareness108. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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49
InvestigationintotheReasonsforIncorrectorIncompletePathologyRequestForms(2008)
RiskMinimisation
50
EnhancingtheQualityUseofPathologyforGPRegistrarsandInternationalMedicalGraduates–AssessingtheNeed(2009)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
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Cognitus Pty Ltd Jane Carstens
Table of Contents
Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result
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Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
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Appendix A – Report Summaries Relevant to Different Themes ................................
Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:109. PromotingEvidence-BasedPractice110. RiskMinimisation111. QualityAssuranceandCapacity–NewTechnology112. eHealthCapability113. PathologyRequestingandReporting–RequesterandConsumer
Focus114. WorkforceCapacityandCompetence115. ConsumerFocusandInformationStrategies116. AccessInitiatives–RaisingAwareness117. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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AccessInitiatives–RaisingAwareness–2outof3
3 2
Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:37. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
38. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategy
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toimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentoftheirmedicaltraining.
39. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online
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MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfunding
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roundsandtargetedinitiatives.TheprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedbyDoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:37. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
38. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
39. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
109. PromotingEvidence-BasedPractice110. RiskMinimisation111. QualityAssuranceandCapacity–NewTechnology
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112. eHealthCapability113. PathologyRequestingandReporting–RequesterandConsumer
Focus114. WorkforceCapacityandCompetence115. ConsumerFocusandInformationStrategies116. AccessInitiatives–RaisingAwareness117. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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51
EffectofaStructuredMicrobiologyLaboratoryReportonAntimicrobialPrescribingforAsymptomaticBacteriuriainElderlyFemales(2010)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:118. PromotingEvidence-BasedPractice119. RiskMinimisation120. QualityAssuranceandCapacity–NewTechnology121. eHealthCapability122. PathologyRequestingandReporting–RequesterandConsumer
Focus123. WorkforceCapacityandCompetence124. ConsumerFocusandInformationStrategies125. AccessInitiatives–RaisingAwareness126. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:40. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
41. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
42. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:40. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
41. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
42. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
118. PromotingEvidence-BasedPractice119. RiskMinimisation120. QualityAssuranceandCapacity–NewTechnology121. eHealthCapability122. PathologyRequestingandReporting–RequesterandConsumer
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Focus123. WorkforceCapacityandCompetence124. ConsumerFocusandInformationStrategies125. AccessInitiatives–RaisingAwareness126. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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IdentifyinghowElectronicDecisionSupport(EDS)inComputerisedPathologyOrderEntrySystemscanImprovePathologyPractice,RationalOrderingandPatientOutcomes(2010)
QualityAssuranceandCapacity–NewTechnology
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
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Table of Contents
Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................
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Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:127. PromotingEvidence-BasedPractice128. RiskMinimisation129. QualityAssuranceandCapacity–NewTechnology130. eHealthCapability131. PathologyRequestingandReporting–RequesterandConsumer
Focus132. WorkforceCapacityandCompetence133. ConsumerFocusandInformationStrategies134. AccessInitiatives–RaisingAwareness135. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:43. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
44. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
45. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:43. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
44. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
45. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
127. PromotingEvidence-BasedPractice128. RiskMinimisation129. QualityAssuranceandCapacity–NewTechnology130. eHealthCapability131. PathologyRequestingandReporting–RequesterandConsumer
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Focus132. WorkforceCapacityandCompetence133. ConsumerFocusandInformationStrategies134. AccessInitiatives–RaisingAwareness135. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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53
ComputerAssistedPatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase1(iNvestigateProject)(2010)
QualityAssuranceandCapacity–NewTechnology
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
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Table of Contents
Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................
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Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:136. PromotingEvidence-BasedPractice137. RiskMinimisation138. QualityAssuranceandCapacity–NewTechnology139. eHealthCapability140. PathologyRequestingandReporting–RequesterandConsumer
Focus141. WorkforceCapacityandCompetence142. ConsumerFocusandInformationStrategies143. AccessInitiatives–RaisingAwareness144. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:46. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
47. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
48. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:46. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
47. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
48. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
136. PromotingEvidence-BasedPractice137. RiskMinimisation138. QualityAssuranceandCapacity–NewTechnology139. eHealthCapability140. PathologyRequestingandReporting–RequesterandConsumer
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Focus141. WorkforceCapacityandCompetence142. ConsumerFocusandInformationStrategies143. AccessInitiatives–RaisingAwareness144. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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54
iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase2(2011)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:145. PromotingEvidence-BasedPractice146. RiskMinimisation147. QualityAssuranceandCapacity–NewTechnology148. eHealthCapability149. PathologyRequestingandReporting–RequesterandConsumer
Focus150. WorkforceCapacityandCompetence151. ConsumerFocusandInformationStrategies152. AccessInitiatives–RaisingAwareness153. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:49. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
50. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
51. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:49. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
50. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
51. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
145. PromotingEvidence-BasedPractice146. RiskMinimisation147. QualityAssuranceandCapacity–NewTechnology148. eHealthCapability149. PathologyRequestingandReporting–RequesterandConsumer
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Focus150. WorkforceCapacityandCompetence151. ConsumerFocusandInformationStrategies152. AccessInitiatives–RaisingAwareness153. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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55
EncouragingQualityPathologyOrderinginAustralia’sPublicHospitals(2011)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:154. PromotingEvidence-BasedPractice155. RiskMinimisation156. QualityAssuranceandCapacity–NewTechnology157. eHealthCapability158. PathologyRequestingandReporting–RequesterandConsumer
Focus159. WorkforceCapacityandCompetence160. ConsumerFocusandInformationStrategies161. AccessInitiatives–RaisingAwareness162. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:52. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
53. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
54. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:52. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
53. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
54. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
154. PromotingEvidence-BasedPractice155. RiskMinimisation156. QualityAssuranceandCapacity–NewTechnology157. eHealthCapability158. PathologyRequestingandReporting–RequesterandConsumer
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Focus159. WorkforceCapacityandCompetence160. ConsumerFocusandInformationStrategies161. AccessInitiatives–RaisingAwareness162. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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PathologyRequestingandReporting–RequesterandConsumerFocus
56
EffectiveCommunicationofPathologyResultsinRequestingPractitionersandConsumers(Current)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
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Table of Contents
Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................
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Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:163. PromotingEvidence-BasedPractice164. RiskMinimisation165. QualityAssuranceandCapacity–NewTechnology166. eHealthCapability167. PathologyRequestingandReporting–RequesterandConsumer
Focus168. WorkforceCapacityandCompetence169. ConsumerFocusandInformationStrategies170. AccessInitiatives–RaisingAwareness171. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:55. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
56. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
57. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:55. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
56. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
57. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
163. PromotingEvidence-BasedPractice164. RiskMinimisation165. QualityAssuranceandCapacity–NewTechnology166. eHealthCapability167. PathologyRequestingandReporting–RequesterandConsumer
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Focus168. WorkforceCapacityandCompetence169. ConsumerFocusandInformationStrategies170. AccessInitiatives–RaisingAwareness171. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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57
iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations(Current)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:172. PromotingEvidence-BasedPractice173. RiskMinimisation174. QualityAssuranceandCapacity–NewTechnology175. eHealthCapability176. PathologyRequestingandReporting–RequesterandConsumer
Focus177. WorkforceCapacityandCompetence178. ConsumerFocusandInformationStrategies179. AccessInitiatives–RaisingAwareness180. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:58. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
59. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
60. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:58. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
59. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
60. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
172. PromotingEvidence-BasedPractice173. RiskMinimisation174. QualityAssuranceandCapacity–NewTechnology175. eHealthCapability176. PathologyRequestingandReporting–RequesterandConsumer
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Focus177. WorkforceCapacityandCompetence178. ConsumerFocusandInformationStrategies179. AccessInitiatives–RaisingAwareness180. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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58
TheImpactoftheImplementationofElectronicOrderingofPathologyRequestingandtheQualityandEffectivenessofHospitalPathologyServices–BuildingaRobustEvidenceBaseandBenefitsFrameworkforSuccessfule-HealthDiffusions(Current)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
Table of Contents
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Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................
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Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:181. PromotingEvidence-BasedPractice182. RiskMinimisation183. QualityAssuranceandCapacity–NewTechnology184. eHealthCapability185. PathologyRequestingandReporting–RequesterandConsumer
Focus186. WorkforceCapacityandCompetence187. ConsumerFocusandInformationStrategies188. AccessInitiatives–RaisingAwareness189. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:61. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
62. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
63. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:61. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
62. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
63. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
181. PromotingEvidence-BasedPractice182. RiskMinimisation183. QualityAssuranceandCapacity–NewTechnology184. eHealthCapability185. PathologyRequestingandReporting–RequesterandConsumer
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Focus186. WorkforceCapacityandCompetence187. ConsumerFocusandInformationStrategies188. AccessInitiatives–RaisingAwareness189. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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eHealthCapability
59
PathWay(2005)
Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports
A Summary Report for the Australian Department of Health and
Ageing Medical Benefits Division
Canberra 22 June 2012
Cognitus Pty Ltd Jane Carstens
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Table of Contents
Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................
Abbreviations ................................................................................................................................
Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................
Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................
Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................
Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................
eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................
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Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................
Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek
TM Point of Care INR
Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................
Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................
Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online
AU Stage 1 (Current) ................................................................................................................................
Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................
Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................
Appendix A – Report Summaries Relevant to Different Themes ................................
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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,
includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent
investmentandcouldinformthefuturestrategicdirectionoftheprogram.
ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:190. PromotingEvidence-BasedPractice191. RiskMinimisation192. QualityAssuranceandCapacity–NewTechnology193. eHealthCapability194. PathologyRequestingandReporting–RequesterandConsumer
Focus195. WorkforceCapacityandCompetence196. ConsumerFocusandInformationStrategies197. AccessInitiatives–RaisingAwareness198. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.
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Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe
ninethemes’]
General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:
Theme Original projects
Follow on initiatives
and projects
PathologyRequestingandReporting–RequesterandConsumerFocus
17 9
PromotingEvidence-BasedPractice
16 10
eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology
8 4
WorkforceCapacityandCompetence
6 10
RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement
4 4
ConsumerFocusandInformationStrategies
3 4
AccessInitiatives–RaisingAwareness–2outof3
3 2
Pathology Requesting & Reporting –…
Promoting Evidence-Based Practice
eHealth Capability
Quality Assurance and Capacity – New …
Workforce Capacity and Competence
Risk Minimisation
Communication Strategy and Stakeholder…
Consumer Focus and Information Strategies
Access Initiatives – Raising Awareness
0 2 4 6 8 10
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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach
theme,thenthenumberoffollowoninitiativesandprojects’]
Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults
beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.
Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.
DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.
Investigateincludingpatient-specificadviceforGPsonpathologytestresults.
FocusonincreasingGPs’understandingofthepathologytestingprocess.
Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:64. Theneedforincreasedinformationresourcesgeneratedbyreliable
sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.
65. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof
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theirmedicaltraining.
66. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.
Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.
Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee
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NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander
Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee
Introduction
Background
TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.
FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby
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DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.
Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:64. Quality Consumer Services:Todevelopandimproveconsumer-
focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;
65. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and
66. Quality Pathology Practice:Tosupportprofessionalpractice
standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.
Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.
Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:
toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and
toproduceadocumentthatwillformarecordofpastand
presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.
TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.
Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:
190. PromotingEvidence-BasedPractice191. RiskMinimisation192. QualityAssuranceandCapacity–NewTechnology193. eHealthCapability194. PathologyRequestingandReporting–RequesterandConsumer
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Focus195. WorkforceCapacityandCompetence196. ConsumerFocusandInformationStrategies197. AccessInitiatives–RaisingAwareness198. CommunicationStrategyandStakeholderEngagement.
Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.
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CommunicationStrategyandStakeholderEngagement
60
TheAustralianPathologyWorkforceCrisis(2008)
CommunicationStrategyandStakeholderEngagement
61
ReviewofPathologySpecialistDevelopmentPathways(2010)
CommunicationStrategyandStakeholderEngagement
62
ImpactofWorkloadofAnatomicalPathologistsonQualityandSafety(2011)
RiskMinimisation
63
SurveyofthePathologyWorkforce(2011)
CommunicationStrategyandStakeholderEngagement
64
CareerStructuresandPathwaysfortheScientificWorkforceinMedicalPathologyLaboratories(2011)
CommunicationStrategyandStakeholderEngagement
65
QualityUseofPathologyConsumerConsultationProject(2010)
CommunicationStrategyandStakeholderEngagement
66
BenefitsandRisksofPathologyTesting(Current)
CommunicationStrategyandStakeholderEngagement
67
LabTestsOnlineAUStage1(Current)
CommunicationStrategyandStakeholderEngagement
68
OptimisingHealthBenefitsforAboriginalPeoplewhotakeWarfarin(2009)
CommunicationStrategyandStakeholderEngagement
69
QualityAssuranceforAboriginalMedical
CommunicationStrategyandStakeholderEngagement
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Services(QAAMS)(Current)
70
QualityAssuranceforAboriginalMedicalServices(QAAMS)QualityAssuranceProgram(Current)
CommunicationStrategyandStakeholderEngagement
71
ReportfromtheNationalWorkshoponSafetyandQualityinPathology(2007)
WorkforceCapacityandCompetence
72
TheSecondNationalWorkshoponSafetyandQualityinPathology(2008)
WorkforceCapacityandCompetence
73
BestPracticeinPathologyRequestingandReportingWorkshop(2009)
PathologyRequestingandReporting–RequesterandConsumerFocus
74
PathologyWorkforceWorkshop(2011)
WorkforceCapacityandCompetenceConsumerFocusandInformationStrategies