[Histonet] Quality Measure for Pathology

[Gudrun Lang]

Linda,
that's exactly what we do here.
I wondered, if you fixed a cut-off. Because in quality-audits they often
asked the "what do you if.."-questions. 
for example: "There is an increase in the number of discrepancies in this
special month. The rate is over your defined aim. What did you do to fix the
problem? Do you keep records about the process of solving the problem?"

I was just curious, if you go further than the counting of events. 
In daily work we often know the causes of mistakes, and very often we know,
that a certain amount of mistakes can't be avoided, although everyone tries
to give his/her best. 
I think QM should help to discover the special events or circumstances, that
raise the number of mistakes above the "normal" level. I was curious, if you
defined this "normal" level for your lab.

Kind regards
Gudrun


-----Ursprüngliche Nachricht-----
Von: Blazek, Linda [mailto:lblazek at digestivespecialists.com] 
Gesendet: Mittwoch, 13. Juni 2018 14:38
An: Gudrun Lang
Cc: histonet at lists.utsouthwestern.edu
Betreff: RE: [Histonet] Quality Measure for Pathology

Gudrun,
Our lab is 95% biopsy specimens.  Therefor the number of pieces counted at
gross is written on the side of the cassette so that at the time of
embedding the tech knows what should be present.  That helps in being sure
there isn't a piece stuck to the lid or forceps, or popped out when opening
the cassette.  It's really more of a Quality Assurance measure than tracking
a discrepancy.  I do watch how frequent there is a discrepancy though and if
there seems to be a pattern will initiate a review of processes for both the
grossing person and the embedding person.  
What we see most is the gross will say one piece and there will actually be
multiple tiny pieces or two pieces will be three at embedding.  As all staff
is aware that we are following this they tend to be much more precise in
counting at grossing and embedding.  
Linda

-----Original Message-----
From: Gudrun Lang [mailto:gu.lang at gmx.at] 
Sent: Wednesday, June 13, 2018 4:19 AM
To: Blazek, Linda
Cc: histonet at lists.utsouthwestern.edu
Subject: AW: [Histonet] Quality Measure for Pathology

Linda,
How do you handle this key figure of discrepancies? Have you set a cut-off
(per person, per day) for any consequencies? What are the
consequencies, besides repeated training?

thanks
Gudrun

-----Ursprüngliche Nachricht-----
Von: Blazek, Linda via Histonet [mailto:histonet at lists.utsouthwestern.edu] 
Gesendet: Dienstag, 12. Juni 2018 18:55
An: Normington Lacy; Amy Self
Cc: histonet at lists.utsouthwestern.edu
Betreff: Re: [Histonet] Quality Measure for Pathology

Also a discrepancy between the number of pieces that are dictated at gross
as being in a cassette compared to what is found in the
cassette at embedding.  You can record the number of blocks that need
re-embedded and the number of slide recuts needed a month. 

Linda

Linda Blazek HT (ASCP)
Pathology Lab Manager
GI Pathology of Dayton
Digestive Specialists, Inc
Phone: (937) 396-2623
Email: lblazek at digestivespecialists.com

-----Original Message-----
From: Normington Lacy via Histonet
[mailto:histonet at lists.utsouthwestern.edu] 
Sent: Tuesday, June 12, 2018 9:34 AM
To: Amy Self; 'histonet at lists.utsouthwestern.edu'
Subject: Re: [Histonet] Quality Measure for Pathology

Some ideas:

Proficiency Testing
Corrected Results (Addendums/Amendment) volume
Turnaround Time Monitoring
Frozen Section TAT (critical call)
Rejected Tests (empty bottles, etc)


-----Original Message-----
From: Amy Self via Histonet [mailto:histonet at lists.utsouthwestern.edu] 
Sent: Tuesday, June 12, 2018 8:18 AM
To: 'histonet at lists.utsouthwestern.edu' <histonet at lists.utsouthwestern.edu>
Subject: [Histonet] Quality Measure for Pathology

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Good Morning,

I am looking for ideas/suggestions for QM Histology/Pathology.  My QM
director wants me to "measure" something that I can place on
the lab dashboard.

Thanks in advance for your help..

Amy Self
Histology Lab Senior Tech
Lab
Tidelands Georgetown Memorial Hospital
606 Black River Road
Georgetown, SC 29440
843-520-8711
ASelf at tidelandshealth.org
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