QUALITY MANAGEMENT PLANS FOR ANATOMIC PATHOLOGY Are they

QUALITY MANAGEMENT PLANS FOR ANATOMIC PATHOLOGY Are they ready yet?

What’s in this packet � � � Quality Management Plan for Surgical Pathology and Non. Gynecologic Cytopathology Quality Management Plan for Autopsy Pathology Attachments A-L

DO WE REALLY HAVE TO READ ALL OF THIS? You must be kidding.

For all pathologists � � � Read the Quality Management Plan for Surgical Pathology and Non. Gynecologic Cytopathology Read the Quality Management Plan for Autopsy Pathology Read Attachment E and Attachment L

What’s Attachment L? � Botttom line information regarding your daily contribution to collecting data

What’s Attachment E? � � � Procedure for creating “QA-Slide Quality” Retrieval Flag in Co. Path Specimen Case # Final Dx Entry/Edit Staff Retrieval Flag From dropdown, select, “QA-Slide Quality” Enter comment (e. g. , “too thick”, “mislabeled”, etc) OK Save/Next Specimen No action and “Yes”

What’s the point of following the steps in Attachment E? � � Weekly report of problems in Histology quality will be generated, sent to Medical Director of Histology, AP Manager, Histology Manager Real time documentation of problems in Histology quality Obviates the need to complete a Histology evaluation every day Satisfies CAP Checklist requirement for feedback to Histology Laboratory

Who needs to read the other attachments? � � � Medical Directors Pathologists in charge of Anatomic Pathology Quality Management Pathologists who oversee Histology and Clerical Staff

What’s in the other attachments? � � � � Templates for monitor reporting List of cases requiring second pathologist review Frozen section TAT data collection form List of monitors to be performed, frequency of reporting, type of monitor (QM vs Peer Review) List of Co. Path reports, frequency, recipient Responsibility of Clerical Assistant at each site for cases sent to extradepartmental pathologist Resonsibility of Histology personnel at each site for Specimen Discrepancy and Lost Specimen info

What has been changed since the last presentation? � � Incorporation of all feedback received Extraneous monitoring removed CAP checklist items referenced in text of plans Modification of OFI’s

OFI’S How did we fix them?

CAN WE PERFORM MONITORS MORE FREQUENTLY? Have fun!

JOAN KOSIEK, CAP LAP Remember her name

What’s NOT in the Plans? � � List of specimens that the HOSPITAL may choose to exclude from routine submission to Pathology Details of qualifications, supervision, and evalutions of PA’s Policy about ESO-who signs your reports if you aren’t there to do it. Everything relating to ER/PR and Her 2

WHEN DO WE START?