Histopathology National QI Programme –

Round 3 targets & recommendations

Dr Ann Treacy, Histopathology QI Programme Working

Group

10 May 2016

Setting Targets for QI Programme

• Targets to date

Targets setSet Monitor Target & Key Indicators

Round 1

Round 2Intradepartmental

Consultation

3- 5 % All Cases (round 1)

3-5% Histo cases (retain)

3-5% Cytology Exfoliative (retain)

7- 9% Cytology FNA

Round 1

Round 2Frozen Section

Correlation

97% Concordance

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

85% TAT < 20 minutes

Round 1 Turn around Time TAT by case type

i. P01 Small Biopsy – 80% day 5

ii. P02 GI Endoscopic Biopsy – 80% day 5

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

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

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

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

Round 2 Intradepartmental

Consultation

2% Adult Autopsy All cases

3

More targets?

• 43 potential KPIs agreed

• Review each & provide rationale for /

against setting

• All sites note that using transparent data,

appropriate to be shared with the public,

HSE managers, etc

• Opportunity to share with hospital

management outside lab, - case for

resources etc

Principles for QA Programme

Performance Indicators; 1. Be clearly defined

2. Be important to the Quality of Patient Care

3. Be a real indicator of performance and relate to issues which local

management systems can influence

4. Have intelligent targets (with performance measured against the

target)

5. Be robust (the quality of the data, its timeliness, the quality of the

analysis and the interpretation of the analysis ) Where PIs are not

as robust as we would like, the limitations of the PIs should be

clearly outlined

6. Be worth the effort - i.e. the burden involved in collecting the data

does not outweigh the usefulness of the PI

7. Inform decisions and actions by management

8. Change as priorities and information needs evolve

Guidance• National data to date

• International literature & input

• Experience

– Professional

– Within the QI programme

• Discussion

• QI programme participants– Survey

– Bulletin

– Workshop

Definitions

• Target

• Recommendation

Interinstitutional Consultation

• Potential targets

– % of total cases referred externally for review

– % agreement of cases referred externally for review

– % of total cases received internally for review

– % agreement of cases received internally for review

– % of total cases referred externally for opinion

Interinstitutional Consultation

• Potential targets

– % of total cases referred externally for review

– % agreement of cases referred externally for review

– % of total cases received internally for review

– % agreement of cases received internally for review

– % of total cases referred externally for opinion

Interinstitutional Consultation

• External referral – learning opportunity

• Disagreements (internally or externally)

– Usually will trigger an amended / corrected report

– Captured under amended / corrected reports targets

• Recommendation that sites internally monitor these

cases for QI

• Review at discrepancy conferences

• Return of slides and reports for cases received for

review / opinion

• Capture of the agreement (Q004) or disagreement

(Q005) code

FS Correlation

• % concordance

• % deferral rate

• % Major discordance

• % Minor Discordance

• Frozen section diagnosis turnaround time

FS Correlation

• % concordance – Round 1: 97%

• % deferral rate – Round 2: 5%, range 1-10%

• % Major discordance

• % Minor Discordance

• Frozen section diagnosis turnaround time –Round 1: 85% <20 min

✓

✓

✓

FS Correlation

• Retain major discordance

• Suggested split into interpretative /

sampling errors – currently not captured

with existing codes

• Review of discordances encouraged

Cyto/Histo Correlation

• % of total cytology cases with histology follow up

per case type

• % discordance

• % false positive cases

• % false negative cases

• % discordance broken into cytology or histology

interpretation or sampling error

Cyto/Histo Correlation

• % of total cytology cases with histology follow up

per case type

• % discordance

• % false positive cases

• % false negative cases

• % discordance broken into cytology or histology

interpretation or sampling error

Cyto/Histo Correlation

• Discontinue use of the Q11 / Q12 codes

• Monitor cytology through focused real time

audit, MDT review etc

• Recommendation

Cytology cases to be monitored using

–Intradepartmental review

–MDT review & discrepancies

–Addenda – corrected / amended

–Communication to clinicians

Retrospective review - focused real time

• % cases reviewed per case type

• % agreement

Retrospective review - focused real time

• % cases reviewed per case type

– Negative cases suggested – prostate biopsies

/ naevi / cervical biopsies

• % agreement

– 95% agreement – target

• Recommendation

– Review of cases with disagreement

– Suggested increase to 10% for locums

Retrospective review - report

completeness

• % cases reviewed per case type

• % completeness

Retrospective review - report

completeness

• % cases reviewed per case type

– Insufficient data currently

– New LIS system may allow for this

– Trial of pancreas and endometrium cases

• % completeness

– Currently modeled on ICCR cases

– Differences locally and nationally

– Recommendation

• Review of report as part of MDT review

• Useful project opportunity

MDT

• no of each conference type held

• % of total cases per case type reviewed at MDT

• % agreement

MDT

• no of each conference type held

– New LIS system may aid this

• % of total cases per case type reviewed at MDT – Cases listed for MDT by clinicians not pathologists -

– Huge variation in numbers between CC and nonCC

– Set target

• CC range 5-29% 15% average

• nonCC range 1-24% 5% average

– Broad recommendation 10%

• CC 10%

• NonCC 5% MDT & 5% q006

–% agreement - 95%

MDT outside pathologist control

Q006 within pathologist control

Combine both for target.

Laboratory based incidents

• % of total cases with low impact incidents at

pre analytic, analytic & post analytic phase

• % of total cases with medium impact

incidents at pre analytic, analytic & post

analytic phase

• % of total cases with high impact incidents at

pre analytic, analytic & post analytic phase

Laboratory based incidents

• % of total cases with low impact incidents at

pre analytic, analytic & post analytic phase

• % of total cases with medium impact

incidents at pre analytic, analytic & post

analytic phase

• % of total cases with high impact incidents at

pre analytic, analytic & post analytic phase

Laboratory based incidents

• Non conformances are covered under

laboratory schemes, Q pulse etc

• Duplication of work done via accreditation

agencies

• Hold codes

• ? Input of new LIMs

Lab based EQA

• list external assessment schemes

participated in by hospital

Lab based EQA

• list external assessment schemes

participated in by hospital

• Not within programme remit – no means to

capture currently

• ? New LIMs system

Addendum Reports

• % corrected reports

• % supplementary reports

• % amended reports

Addendum Reports

• Definitions still differ

– Interpretative error – issue amended report

– Non interpretative error – typo / sampling – issue

corrected report

– Additional information – issue supplementary report

• Report as non conformance to evaluate through

participant local risk matrix to assess impact on patient

care

• Volumes of supplementary reports can vary from unit to

unit

• Review of supplementary reports (Q20) can locate

incorrectly coded amended and corrected reports

Addendum Reports

• % corrected reports

– Target Range 2 – 5%

• % supplementary reports

– Target Range 2-10%

• % amended reports

– Target Range 0.1 – 1%

Communication

• % of total cases reported to clinician by

pathologist

Communication

• % of total cases reported to clinician by

pathologist

• Recommendation

– 1-2% as per audit presented at USCAP

– Encourage communication with clinicians

– Development of inexhaustive critical diagnosis

list through the Faculty of Pathology

– Separate code for CD to be developed

Autopsy retrospective review

• % of total cases with toxicology, histology,

brain retention, other organ retention

• % cases reviewed per case type & review

type

• % satisfactory

• % unsatisfactory

Autopsy retrospective review

• % of total cases with toxicology, histology,

brain retention, other organ retention

• % cases reviewed per case type & review

type

• % satisfactory - Target 90%

• % unsatisfactory

– Autopsy M&M meetings – 1% cases per year

Round 3 – settable targetsMonitor (Key

Quality Area)

Target & Key Indicators Notes

Multi-

disciplinary

Team

Meetings

(MDT)

Q017 - % MDT Completed, recommendation

10% total cases

While the programme is aware that cases listed for MDT

are outside of pathologist direct control MDT review is an

important peer review activity. Hence 10% total

recommended.

Addendum

reports Q021- % Amended Reports less than 1%, not

0

Q022 - % Corrected Reports : less than 5%,

not 0

Q020 - % Supplementary Reports: 2-10%

range (note: exclude breast (existing checks

and balances) as it skews data from all other

Primary Organ sites

Clarity on the coding & types of addendum reports is

needed from review of existing data there is variability in

if/how addenda and additional information is recorded.

Definitions updated:

i. Amended report = interpretive error,

ii. Corrected report= non-interpretive errors, e.g. typo

iii Supplementary report = additional information.

Programme recognises that laboratory casemix can impact

supplementary report rate.

Round 3 – settable targetsMonitor (Key

Quality Area)

Target & Key Indicators Notes

Retrospective

review – Autopsy

% satisfactory = 90% Number of cases to be reviewed to be decided locally.

Autopsy

Morbidity &

Mortality (M&M)

meeting

1% of cases presented per year at

hospital M&M conference

M&M conferences are typically those that are presented at

hospital Medical and Surgical Grand Rounds.

FS Correlation % Discordance = 3% (major only) Updating definition to major discordance only due to lack of

international evidence for definition of "major" vs. "minor“

Retrospective

Review

Q013 - % Real time review

Agreement: ≥95%

Disagreement is defined as when it is deemed necessary to

issue an amended report.

Programme guidance suggests locum / new consultants 10%

rate of review for 1 month minimum (local site arrangements

may vary).

Data improvements

• The timeliness, volume and accuracy of data is improving.

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

– increases profile of histopathology

– facilitates further quality improvement.

• Help to share learning through the programme and hospital groups

– Areas for development

– Areas of best practice

Key to graphs & data report

• Anonymised aggregated data – per data bulletin issued last

week & National Data Report available today.

• CC: Cancer Centre

• NonCC / NC – hospital that is not a cancer centre, can include

maternity, children’s, general etc

• Red horizontal line: target (min. to be achieved)

• Yellow horizontal line: target (ideal to be achieved)

• Dark blue plot line: average of all sites uploaded

• Purple plot line: average of all CC data uploaded

• Pale blue plot line: average of all non CC data uploaded

Key messages• Table from target annual review analysis

provides # of cases for 12 months

of 2015 Jan – Dec by anonymised site,

cancer centre (CC),

general centre (NC) and all.

Red text indicates site below the target.

• Variability of sites, with some clusters

QI Programme Aim: reduce variability

raise standards overall

• It is difficult for individual sites to see

they are an outlier unless this type of

anonymised data is provided to them.

• Feedback welcome – aim for sites to

get context to prioritise issues and

understand where to prioritise & progress

Questions?