Difference between revisions of "Quality"

Jump to navigation Jump to search
7,530 bytes added ,  17:27, 14 February 2017
 
(41 intermediate revisions by the same user not shown)
Line 1: Line 1:
'''Quality''', in pathology, has got a lot of attention lately because there have been high profile screw-ups that lead to significant harm.<ref>URL: [http://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/index.html http://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/index.html]. Accessed on: 1 March 2011.</ref><ref>Judicial inquiry probes faulty breast cancer tests. CBC website. URL: [http://www.cbc.ca/news/background/cancer/inquiry.html http://www.cbc.ca/news/background/cancer/inquiry.html]. Accessed on: 30 January 2012.</ref>
'''Quality''', in pathology, has got a lot of attention lately because there have been high-profile irregularities that lead to significant harm.<ref>URL: [http://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/index.html http://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/index.html]. Accessed on: 1 March 2011.</ref><ref>Judicial inquiry probes faulty breast cancer tests. CBC website. URL: [http://www.cbc.ca/news/background/cancer/inquiry.html http://www.cbc.ca/news/background/cancer/inquiry.html]. Accessed on: 30 January 2012.</ref>


==General==
=General=
The keys to ''quality'' are understanding the:  
The keys to ''quality'' are:
#Needs of the stakeholders (surgeons, oncologists, patients, other pathologists, the public at large).
#Understanding the needs of the stakeholders (surgeons, oncologists, patients, other pathologists, the public at large).
#Processes.
#Understanding the processes.
#Developing measures of quality.
#Developing measures of quality.
#Tracking the measures of quality & assessing their validity.
#Tracking the measures of quality & assessing their validity.
#Understanding the causes of failures/adverse events in the context of the processes.
#Understanding the causes of failures/adverse events in the context of the processes.
#Continually doing all of the above with the aim of improving outcomes - continuous quality improvement.


==Analysis==
=Definitions=
==System documentation and description==
Quality Management Program-Laboratory Services (QMP-LS) defines a hierarchy of documentation:<ref name=qmpls_org>URL: [http://www.qmpls.org/LaboratoryAccreditation/OLAActivitiesEducationalTools/OLAPresentations/tabid/111/id/11/Default.aspx) http://www.qmpls.org/LaboratoryAccreditation/OLAActivitiesEducationalTools/OLAPresentations/tabid/111/id/11/Default.aspx)]. Accessed on: 18 April 2012.</ref>
*Policy.
*Process
*Procedures.
 
===Policy===
*High level document
*Describes rationale for processes, defines goals/objectives - includes parameters that can be measured.
 
===Process===
*Intermediate level document.
*Defines input and outputs, outlines the steps taken to achieve an objective - should ''not'' be overly detailed.
 
===Procedure===
*Low level document.
*Detailed line-by-line instructions - description of the workflow.
 
==Other==
===Quality control===
*Examines whether a process is hitting its target(s) for its measure(s) of quality.
 
In short: ''Does it hit the targets?''
===Quality assurance===
*Program to insure that a process is yielding the desired output(s).
 
In short: ''Does it produce the desired output?''
 
=Analysis=
===Overview===
===Overview===
Quality issues can be examined in a number of different ways.
Quality issues can be examined in a number of different ways.
Line 35: Line 65:
*Remedy the source of error.
*Remedy the source of error.


A common way to break down error analysis is:  
====The classic structural break down====
A classic structural break down for error analysis is:  
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Errors in pathology}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Errors in pathology}}
Line 41: Line 72:
{{familytree | | | | B01 | | | B02 | | | B03|B01=Pre-analytical errors|B02=Analytical errors|B03=Post-analytical errors }}
{{familytree | | | | B01 | | | B02 | | | B03|B01=Pre-analytical errors|B02=Analytical errors|B03=Post-analytical errors }}
{{familytree/end}}
{{familytree/end}}
Note:
*This break down is arbitrary and ''in of itself'' most useful for answering exam questions.
*In a practical context, it is a frame work for classifying errors.  It is ''not'' useful for understanding the source of an error or addressing it.


====Pre-analytic errors====
====Pre-analytic errors====
Line 60: Line 95:
*Filing problem/lost report.
*Filing problem/lost report.
*Interpretation of report problem (poorly written report, misinterpretation).
*Interpretation of report problem (poorly written report, misinterpretation).
==Sources of error==
*"Human error".
**Training.
**Work flow.
*Process gaps.
**Process control.
**Lack of redundancy.


==Types of errors==
==Types of errors==
Can be subdivided into the following groups:<ref>{{Cite journal  | last1 = Renshaw | first1 = AA. | title = Measuring and reporting errors in surgical pathology. Lessons from gynecologic cytology. | journal = Am J Clin Pathol | volume = 115 | issue = 3 | pages = 338-41 | month = Mar | year = 2001 | doi = 10.1309/M2XP-3YJA-V6E2-QD9P | PMID = 11242788 }}</ref>
*False-negative - missed diagnosis.
*False-positive - diagnosis made that on review considered not to be present.
*Threshold - difference of opinion regarding a diagnostic threshold.
*Type and grade.
*Missed margin.
*Other.
==Grading of errors==
May be subdivided by three groups:
*Grade 1: no consequence.
*Grade 1: no consequence.
*Grade 2: possible consequence.
*Grade 2: possible consequence.
*Grade 3: definitely a consequency.
*Grade 3: definitely a consequence.


==Error reduction==
==Error reduction==
Line 79: Line 132:
**Allow correlation with test.
**Allow correlation with test.
***The interpretation may differ if the history says "screening coloscopy" versus "large cecal mass, anemia and weight loss" versus "breast cancer".
***The interpretation may differ if the history says "screening coloscopy" versus "large cecal mass, anemia and weight loss" versus "breast cancer".
*The use of algorithms to guide decisions where applicable.<ref>Kahneman D. ["Als wären wir gespalten": Der Psychologe und Nobelpreisträger Daniel Kahneman über die angeborenen Schwächen des Denkens, trügerische Erinnerungen und die irreführende Macht der Intuition]. Der Spiegel. Nr. 21. 2012. URL: [http://www.spiegel.de/spiegel/print/index-2012-21.html http://www.spiegel.de/spiegel/print/index-2012-21.html].</ref>
**Remove subjectivity.
**Increase objectivity, reproducibility.


Other strategies:
==Dealing with diagnostic errors==
*Statistical process control.
*Opinion is split on whether reports should be ''amended'' or ''addended'' - see ''[[sign out]]'' article.


==Sources of error==
=Measures of quality=
*"Human error".
**Training.
**Work flow.
*Process gaps.
**Process control.
**Lack of redundancy.
 
 
==Biopsy size==
Very small tissue fragments are associated with a decreased diagnostic yield and an increased diagnostic uncertainty.
 
==Measures of quality==
Any number of parameters can be used to measure quality. The when, where and how-often something is measured depends on the value-added.
Any number of parameters can be used to measure quality. The when, where and how-often something is measured depends on the value-added.


Line 107: Line 151:
*''Error'', in the context of a measurement, has to be defined.
*''Error'', in the context of a measurement, has to be defined.


===Internal measures of quality===
====Smaller categories====
====Smaller categories====
Smaller categories - errors:<ref name=pmid19851132>{{Cite journal  | last1 = Nakhleh | first1 = RE. | title = Core components of a comprehensive quality assurance program in anatomic pathology. | journal = Adv Anat Pathol | volume = 16 | issue = 6 | pages = 418-23 | month = Nov | year = 2009 | doi = 10.1097/PAP.0b013e3181bb6bf7 | PMID = 19851132 }}</ref>
Smaller categories - errors:<ref name=pmid19851132>{{Cite journal  | last1 = Nakhleh | first1 = RE. | title = Core components of a comprehensive quality assurance program in anatomic pathology. | journal = Adv Anat Pathol | volume = 16 | issue = 6 | pages = 418-23 | month = Nov | year = 2009 | doi = 10.1097/PAP.0b013e3181bb6bf7 | PMID = 19851132 }}</ref>
Line 135: Line 180:
**Report delivered to appropriate person?
**Report delivered to appropriate person?


==Immunohistochemistry==
===External measures of quality===
====Benchmark====
*An external quality measure, i.e. a comparison to an outside group or agency.
**Slides are sent around from an external source:
***Lab has to stain 'em and send 'em back for an assessment.
***Pathologists render diagnoses on 'em and are given the (externally rendered) consensus diagnosis.
 
=Immunohistochemistry=
{{Main|Immunohistochemistry}}
{{Main|Immunohistochemistry}}


Work-up of suspected IHC problems:
===Classification of IHC tests===
IHC tests are classified in a paper by Torlakovic ''et al.'':<ref name=pmid20154273>{{Cite journal  | last1 = Torlakovic | first1 = EE. | last2 = Riddell | first2 = R. | last3 = Banerjee | first3 = D. | last4 = El-Zimaity | first4 = H. | last5 = Pilavdzic | first5 = D. | last6 = Dawe | first6 = P. | last7 = Magliocco | first7 = A. | last8 = Barnes | first8 = P. | last9 = Berendt | first9 = R. | title = Canadian Association of Pathologists-Association canadienne des pathologistes National Standards Committee/Immunohistochemistry: best practice recommendations for standardization of immunohistochemistry tests. | journal = Am J Clin Pathol | volume = 133 | issue = 3 | pages = 354-65 | month = Mar | year = 2010 | doi = 10.1309/AJCPDYZ1XMF4HJWK | PMID = 20154273 }}</ref>
*''Class I'':
**Results used by pathologists.
**Adjunct to histomorphology.
**Examples: CD45, S-100.
*''Class II'':
**Used by clinicans for treatment decisions.
**Considered independent of the other information in the pathology report; thus, cannot be derived from other information in the report.
**Examples: ER, PR, HER2, Ki-67, CD117, CD20.
 
The implication of irregularies in the different classes are different. Problems in ''Class II'' tests are potentially more severe, as there is no internal control.
 
===Work-up of suspected IHC problems===
*Review controls (internal and external).
*Review controls (internal and external).
**Isolated to case vs. larger problem?
**Isolated to case vs. larger problem?
Line 152: Line 217:
#Counterstaining.
#Counterstaining.
#Interpretation problem.
#Interpretation problem.
#*Known/expected epitope cross-reactions, e.g. CMV & HSV.<ref name=pmid3029407>{{Cite journal  | last1 = Balachandran | first1 = N. | last2 = Oba | first2 = DE. | last3 = Hutt-Fletcher | first3 = LM. | title = Antigenic cross-reactions among herpes simplex virus types 1 and 2, Epstein-Barr virus, and cytomegalovirus. | journal = J Virol | volume = 61 | issue = 4 | pages = 1125-35 | month = Apr | year = 1987 | doi =  | PMID = 3029407 | PMC = 254073
#*Known/expected epitope cross-reactions, e.g. [[CMV]] & [[HSV]].<ref name=pmid3029407>{{Cite journal  | last1 = Balachandran | first1 = N. | last2 = Oba | first2 = DE. | last3 = Hutt-Fletcher | first3 = LM. | title = Antigenic cross-reactions among herpes simplex virus types 1 and 2, Epstein-Barr virus, and cytomegalovirus. | journal = J Virol | volume = 61 | issue = 4 | pages = 1125-35 | month = Apr | year = 1987 | doi =  | PMID = 3029407 | PMC = 254073 |
URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC254073/?tool=pubmed }}</ref>  
URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC254073/?tool=pubmed }}</ref>  
#*Unknown/unexpected epitope cross-reactions.
#*Unknown/unexpected epitope cross-reactions.
Line 159: Line 224:
*Problems can arise at any step.
*Problems can arise at any step.


===Classification of IHC tests===
=Other=
IHC tests are classified in a paper by Torlakovic ''et al.'':<ref name=pmid20154273>{{Cite journal  | last1 = Torlakovic | first1 = EE. | last2 = Riddell | first2 = R. | last3 = Banerjee | first3 = D. | last4 = El-Zimaity | first4 = H. | last5 = Pilavdzic | first5 = D. | last6 = Dawe | first6 = P. | last7 = Magliocco | first7 = A. | last8 = Barnes | first8 = P. | last9 = Berendt | first9 = R. | title = Canadian Association of Pathologists-Association canadienne des pathologistes National Standards Committee/Immunohistochemistry: best practice recommendations for standardization of immunohistochemistry tests. | journal = Am J Clin Pathol | volume = 133 | issue = 3 | pages = 354-65 | month = Mar | year = 2010 | doi = 10.1309/AJCPDYZ1XMF4HJWK | PMID = 20154273 }}</ref>
==Data retention standards==  
*''Class I'':
*There are data retention standards - how long results have to be retained.
**Adjunct to histomorphology.
 
**Examples: CD45, S-100.
===College of American Pathologists===
*''Class II'':  
*In the United States, there are standards from ''College of American Pathologists'' (CAP) and ''Clinical Laboratory Improvement Amendments'' (CLIA).<ref>URL: [http://www.cms.gov/clia/ http://www.cms.gov/clia/]. Accessed on: 1 April 2012.</ref>
**Considered independent of the other information in the pathology report; thus, cannot be derived from other information in the report.
 
**Used directly for treatment decisions.
Selected CAP and CLIA standards:<ref>URL: [http://home.ccr.cancer.gov/lop/intranet/policymanual/generalpolicy/CAPCLIA.asp http://home.ccr.cancer.gov/lop/intranet/policymanual/generalpolicy/CAPCLIA.asp]. Accessed on: 1 April 2012.</ref>
**Examples: ER, PR, HER2.
*Cytology slide (non-fine needle aspiration): 5 years from the exam date.
*Fine needle aspiration: 10 years from the exam date.
*Histopathology slides: 10 years from the exam date.
 
===Canadian Association of Pathologists===
The Canadian standards are higher than the US ones.


The implication of irregularies in the different classes are different. Problems in ''Class II'' tests are potentially more severe, as there is no internal control.
Summary of selected suggestions:<ref>URL: [http://cap-acp.org/guide_retention-human-biologic-material.cfm http://cap-acp.org/guide_retention-human-biologic-material.cfm]. Accessed on: 6 May 2012.</ref>
{| class = "wikitable sortable"
! Material
! Origin
! Suggested retention period
! Additional notes
|-
| Wet tissue
| surgical
| 4 weeks after final report
| -
|-
| Paraffin blocks
| surgical
| 20 years
| 50 years for paediatric cases
|-
| Slides
| surgical
| 20 years
| -
|-
| Wet tissue
| autopsy
| 3 months after final report
| Coroners'/medical examiner cases may be longer
|-
| Paraffin blocks
| autopsy
| 10 years
| Coroners'/medical examiner cases may be longer
|-
| Slides
| autopsy
| 10 years
| Coroners'/medical examiner cases may be longer
|-
|}


==Other==
==Failure-potential analysis==
===Failure-potential analysis===
Adapted from Ullman:<ref name=ullman>{{cite book |title=The mechanical design process |last= Ullman |first = David G. |authorlink= |coauthors= |year= 1997 |publisher= McGraw-Hill Companies Inc. |location= Toronto|isbn=0-07-065756-4 |page= |pages= |url= |accessdate=}}</ref>
Adapted from Ullman:<ref name=ullman>{{cite book |title=The mechanical design process |last= Ullman |first = David G. |authorlink= |coauthors= |year= 1997 |publisher= McGraw-Hill Companies Inc. |location= Toronto|isbn=0-07-065756-4 |page= |pages= |url= |accessdate=}}</ref>
#Identify potential individual failures.
#Identify potential individual failures.
Line 179: Line 285:
#Identify the corrective action.
#Identify the corrective action.


==See also==
==Biopsy size==
Very small tissue fragments are associated with a decreased diagnostic yield and an increased diagnostic uncertainty.
 
=Quality standards organization=
There are a large number of organizations that have written standards for quality in laboratory medicine.
 
==International==
===International standards organization===
*Abbreviated ''ISO''.
 
Standard:
*ISO 15189:2007.<ref>URL: [http://www.iso.org/iso/iso_catalogue/catalogue_ics/catalogue_detail_ics.htm?csnumber=42641 http://www.iso.org/iso/iso_catalogue/catalogue_ics/catalogue_detail_ics.htm?csnumber=42641]. Accessed on: 18 April 2012</ref>.
**Published in 2007. Supersedes a standard published in 2003.
 
Note:
*Unfortunately one has to shell out money to get a peak at 'em.
 
==United States of America==
===Clinical laboratory improvement amendments===
*Abbreviated ''CLIA''.
*Published a multitude of standards & guidelines.<ref>URL: [http://www.cms.hhs.gov/Regulations-and-Guidance/Legislation/CLIA/index.html?redirect=/clia/ http://www.cms.hhs.gov/Regulations-and-Guidance/Legislation/CLIA/index.html?redirect=/clia/]. Accessed on: 18 April 2012.</ref>
 
===College of American Pathologists===
*Do laboratory accreditation.<ref>URL: [http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=laboratory_accreditation%2Faboutlap.html&_state=maximized&_pageLabel=cntvwr http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=laboratory_accreditation%2Faboutlap.html&_state=maximized&_pageLabel=cntvwr]. Accessed on: 18 April 2012.</ref>
 
==Canada==
===Canadian immunohistochemistry quality control===
*Abbreviated ''CIQC''.
*[https://ciqc.ca/Pages/default.aspx CIQC webpage (ciqc.ca)]
 
===Ontario===
*[[Institute for Quality Management in Healthcare]] - previously ''Quality Management Program - Laboratory Services''.
**Set-up by the ''Ontario Medical Assocation''.
 
==United Kingdom==
*National Pathology Benchmarking Service (NPBS).<ref>URL: [http://www.keele.ac.uk/pharmacy/general/npbs/ http://www.keele.ac.uk/pharmacy/general/npbs/]. Accessed on: 18 April 2012.</ref>
 
=See also=
*[[Critical values]].
*[[Critical values]].
*[[CAP checklists]].
*[[CAP checklists]].
*[[Tissue floater]].
*[[Histology artifacts]].
*[[Waffle diagnosis]].
*[[Workload measurement]].
*[[Anatomical pathology laboratory processes]].


==References==
=References=
{{Reflist|2}}
{{Reflist|2}}
=External links=
*[http://www.keele.ac.uk/pharmacy/general/npbs/ UK national benchmarking (keele.ac.uk)].
*[http://www.westgard.com/westgard-rules-and-multirules.htm Multirule quality control - (westgard.com)] - statistical process control explained for the mathematically challenged.


[[Category:Quality]]
[[Category:Quality]]
48,448

edits

Navigation menu