Dr. Leena Elizabeth Joseph Consultant Histopathologist MFT
You are a junior consultant and have been asked to cover the Skin MDT. Here’s a report from one of the cases reported by a senior consultant in the department . (you find important parameters like Breslow thickness and presence of ulceration have been omitted.) What are your comments on this report?
The cancer dataset publications aim to: • achieve consistent terminology and content in histopathology reporting to facilitate liaison in multidisciplinary teams (MDTs) and collaboration between cancer units and centres aid patient management and treatment by providing the histopathological information necessary to assist clinical decision-making by the MDT provide accurate prognostic information for the patient and clinician create a common database for clinical audit and effectiveness and to provide feedback to clinicians with regard to their quality of treatment • provide accurate data for cancer registration
MDT recommendations are only as good as the information upon which they are based. If there are concerns that key data is missing, this should be documented. Where a recommendation cannot be made because of incomplete data or where new data becomes available at a later stage, it should be possible to bring the patient case back to the MDT for further discussion The role of the lead pathologist and attending pathologists in the multidisciplinary team March 2014
On reviewing the case you find that this is not an isolated case and there are a few cases in which you disagree with the diagnosis made by the same colleague. In particular there is a case in which you feel is a melanoma reported as being benign.
What will you do?
Check your interpretation of the slide was correct and then discuss with the reporting pathologist
The reporting pathologist disagrees with your diagnosis of the case- What do you do?
Opinion of an independent specialty pathologist working in a laboratory to whom material is regularly referred (as agreed in local CPA referral documentation) would normally be used and that the opinion of this specialist given weight in any further consideration. The opinion of all reporting pathologists should be made known to the MDT responsible for making management decisions, together with a consensus view where this can be achieved.
regarded as a performance issue and discussed with a relevant medical director. It is recognized that diagnostic isolation and failure to share case material for review is a characteristic of medical practitioners who perform poorly.
Stage 1- Raise concern with the Head of department or next level of management Risk-management strategies
◦ regular and systematic audit of the diagnostic service and the generation of performance indicators for comparison, where appropriate, with national standards.
Clinical governance strategy- systems for incident
reporting, internal and external quality assurance and handling complaints.
Most errors are sporadic, but excessive workload, diverse professional demands, professional isolation and personal factors may lead to an unacceptable error rate. If there is a persistent problem, the reasons for this will need to be addressed; it is in this area that a performance review may be required.
All doctors make occasional mistakes but, where it is suspected that an individual is not performing to an acceptable standard, the Clinical Director or Head of Department should seek local advice. Refer to RCPAth UPDATED PERFORMANCE REVIEW GUIDES Sept 2017
Performance is a multi faceted construct influenced by numerous factors.
Classification of discrepancies /Errors Category 1: A diagnostic error , which is likely to have a definite influence on clinical management and possible outcome. Category 2; A misinterpretation or oversight , which has the potential to affect clinical management or outcome. Category 3: A minor discrepancy of disease categorisation , which is likely to be of little clinical significance RCPath document(2006)
Discrepancy-defined as a difference of opinion between the original interpretation and the interpretation at review. A discrepancy can only be considered as an error when the discrepancy is confirmed by two independent reviewers.
Discrepancies are evaluated for two distinct purposes.
1. Response to an expression of concern about a doctor’s performance
Guide to conducting an investigative audit of cellular pathology practice August 2017
2.Duty of care review
Guide to conducting a duty of care review March 2014
Category Description (expression of concern)
A B
Inadequate dissection, sampling or macroscopic description. Discrepancy in microscopy
C
Discrepancy in clinical correlation
D
Failure to seek a second opinion in an obviously difficult case Discrepancy in report
E
1. A diagnosis which one is surprised to see from any pathologist(e.g. an obvious cancer reported as benign) 2.A diagnosis which is fairly clearly incorrect, but which one is not surprised to see a small percentage of pathologists suggesting 3.A diagnosis where inter-observer variation is known to be large
Failure to answer the clinical question, despite that the answer being evident from the material available. Failure to indicate that a specimen is clearly inadequate to answer the clinical question.
Category (duty of care) 1
Description
2
Minimal harm (no morbidity)
3
Minor harm (minor morbidity)
4
Moderate harm (moderate morbidity)
5
Major harm (major morbidity)
No impact on care
The College recommends that professional standards and performance are best maintained through: participation in CPD participation in clinical audit and audit of own performance participation in annual appraisal or individual performance review processes receiving and acting on feedback and peer review processes practicing to meet external clinical targets ensuring the best possible clinical outcomes.
You are newly appointed consultant in a department and have taken over the job of a senior consultant after his retirement. After a few weeks into your job your secretary calls you to say that a medical representataive wants to talk to you.The medical rep is very polite and pleasant and after initial formalities informs you that your predecssor had an arrangement with her to allow use of tissue from specimens for her research purposes. She offers to discuss this arrangement in detail over dinner/lunch at the town’s best restaurant.
What are your thoughts on this? Would you go for the meal? How would you manage this situation-would you agree to let her have access to tissue?
Research requires approval by RECs It is good practice to obtain prior consent to use surplus tissue in an external arrangement with a commercial company (unless the work is a REC approved research project using anonymised tissue). RCPath -Guidance on the use of clinical samples retained in the pathology laboratory (September 2012)
Where there is doubt concerning a project, the National Research Ethics Service and/or appropriate REC should be consulted so that a valid independent view can be obtained on the acceptability of a particular course of action.
Code A – ‘Guiding principles and the fundamental principle of Consent’ Code B – Post-mortem examinations Code C – Anatomical examination Code D – Public display Code E – Research Code F – Donation of solid organs for transplantation Code G – Donation of allogeneic bone marrow and Peripheral Blood and Stem Cells
HTA Code of Practice Version 14 (Updated July 2014)
Diagnostic tissue can only be released for research under the following circumstances: When the patient has given consent for use of their tissue in research (the preferable scenario); or When the tissue will be released to the researcher in a non-identifiable form; and When the tissue will be used in a project that has approval by a recognised research ethics committee .
E.g. – A researcher wishes to use paraffinembedded blocks of surgically removed thyroid tissue stored in the archives of a pathology department after its use for diagnosis. As the patient had not given their consent for the use of their tissue for research, it can only be released from the diagnostic archive if it does not identify the patient and is used in a specific project that has been approved by a research ethics committee (REC).
Research- The attempt to derive generalisable new knowledge including studies that aim to generate hypotheses as well as studies that aim to test them Addresses clearly defined questions, aims and objectives. Quantitative research – designed to test a hypothesis. Qualitative research – identifies/explores themes following established methodology. Audit- Designed and conducted to produce information to inform delivery of best care Measures against a standard Designed to answer the question: “Does this service reach a predetermined standard?”
RESEARCH REQUIRES R.E.C. REVIEW
AUDIT DOES NOT REQUIRE R.E.C. REVIEW
You are a junior consultant and you notice that one of your senior colleagues coming out of a pub and appears to be unsteady on his feet. On two other previous occasions you had smelt alcohol on his breath whilst at an afternoon MDM, but had let it go as he had conducted the meeting reasonably. What will you do now?
Colleagues are often well placed to recognise problems when they arise. Acting on a concern about a colleague may be difficult, but it is important for healthcare professionals to do so if they have genuine and significant concerns
Severe anxiety and emotional exhaustion Depression and suicide Alcohol and substance misuse/addiction Eating disorders Post traumatic stress disorder Phobias Panic disorder
Examples of where significant concerns may arise include: poor clinical performance; ill-treatment of patients; unacceptable behaviour, such as unlawful discrimination, harassment or bullying of staff or patients; breach of sexual or other boundaries with patients or staff; poor teamwork that compromises patient care; health problems leading to poor practice; non-compliance with professional codes of conduct; poor management or administration that compromises patient care; .
the starting point will be to contact your line manager or the designated lead
It is important that you, personally, do not try and investigate any concern you may have about a colleague in order to obtain evidence to support your concern. It is possible that such acts could amount to misconduct on your part, and it is therefore strongly recommended that any investigatory action is left to your line manager or the lead officer, as appropriate
The lead officer is responsible for recording and investigating your concern and making sure appropriate action is taken. The Medical Director is usually responsible for ensuring that there is a clearly understood process via which doctors can report their concerns about the conduct, performance or health of medical colleagues
The lead officer will normally contact the practitioner and tell them that a concern about their performance and/or conduct has been raised. Examples of when they might not do this are; if the concern involves a suspected criminal or fraudulent incident, or if telling the practitioner could jeopardise an investigation.
POSSIBLE COURSES OF ACTION Employee with potential problem Employee requests help voluntarily before work performance problem identified
Line manager approaches employee with potential problem
Employee accepts help & consequent referral to Occupational Health
Help provided
Situation resolved & employee satisfied
Employee rejects help offer
Alcohol/drug/solvent abuse problem identified
Out of programme Improvements made Work problems do not continue
No alcohol/drug/solvent abuse problem identified Referred back to line manager
If no improvement and work problems continue
Problem dealt with by Individual/Occupational Health/Agency If not resolved
Out of programme
Appropriate disciplinary action taken and further help offered.
If resolved
Out of programme
If work problems continue to reoccur appropriate action in accordance with appropriate policies
A difficult situation to handle. Colleagues who appear to behave in a difficult way maybe reflecting the environment in which they work
?dysfunctional team /?bad leadership.
What to do?
Take advice from the clinical director Check relevant policy in your hospital intranet e.g. Performance, harassment, grievance May need to collect evidence to support your case –minutes of meeting or a diary If matter is not resolved informally ,then resort to formal procedures-written grievance to the next level-Medical director and obtain professional support and advice.
If your concern is about a dentist, doctor or pharmacist, the organisation may seek the help of the National Clinical Assessment Service (NCAS). NCAS can provide advice on local procedures and may assess the practitioner and offer recommendations for addressing any difficulties identified
NCAS offers: Advice – from experts with backgrounds in clinical practice, healthcare and human resources management, signposting to other resources to help you manage the concern. Specialist interventions – including facilitation, mediation, performance assessment, action planning and back to work support. Shared learning – from their case experience, evaluation and research.
Every MDT should have a designated lead pathologist. The lead pathologist should regularly report specimens from patients under the care of the MDT -participation in EQA relevant to that MDT necessary.
Keep departmental Standard operating protocols(SOP) in the given speciality uptodate. Case review- self review; double reporting. Oversee provision of pathology data for local audits and national reporting. CPD in areas of special interest and inform colleagues working in the same speciaity of new developments.
Developing the service- introducing NICE guidelines; operational or budgetary changes etc. Lead in training /research
e.g: Implementing Standards for integrated reporting in cellular pathology-January 2017
Staffing- time for preparation and attendance incorporated as direct clinical care into job plan. Attendance at business meeting and cancer network groups as supporting professional activities. Trainee pathologists encouraged to attend and present at meetings.
Lord Carters report- improve efficiency by managed networks(2006,2008,2016). NHS Improvement has called on trusts to draw up business plans to consolidate services to improve productivity.
networks are cheaper than the current disconnected, independent hospital-based laboratories improve patient care by standardisation and the use of common data management systems
regional off-site facilities . Or networks of hospital based laboratories working in collaboration
The ‘preferred approach’- Consolidation of services for a ‘cold’ laboratory in each SHA, with local ‘hot’ laboratories on acute hospital sites only where there is clinical need.
Consolidation of services highly dependent on good transport and IT!! Through local partnerships, pathology services can develop supportive networks that enable good practice to be shared and solutions found in order to meet local needs and challenges.
Only 'real' test of the quality of a medical laboratory service is its effect on patient outcomes. Anything else is a surrogate measure. A proper evaluation of the quality of a laboratory service must include a balanced assessment of the entire, end-to-end service to patients.
The provision of readily available, high quality clinical advice The availability, speed and reliability of phlebotomy and specimen transport services The quality of the laboratory processes. The quality of laboratory output. The speed and reliability of results delivery.
- efficient uses of resources, -demand management -appropriate training programmes - skill mix
Appropriate financial resources, stable management and governance • A programme for replacement and updating of equipment • A programme for the introduction of new tests and the elimination of obsolete tests • A training and education programme that not only keeps current staff up to date, but also trains new staff at an appropriate rate to replace those who retire.
National framework of standards through which laboratories can demonstrate the clinical effectiveness of their services
Additional information that the laboratories can provide as evidence to UKAS (United kingdom accreditation services assessors)
Pathology Quality Assurance Review
Chaired by Dr Ian Barnes January 2014
Understanding the existing system: the current assurance framework The need for change -Looking ahead: the changing nature of pathology in the NHS The way forward -Training and development for quality -The External Quality Assurance (EQA) Framework
PQAD November 2019
NHS long term plan Workload management Double reporting On call rotas Digital pathology The future for laboratory management Quality assessment in pathology
Read recent college bulletins, Histopathology journals
NHS Long term Plan Jan 2019 Lord
Carter’s report on operational productivity, February 2016 Achieving
world-class cancer outcomes: Takingcharge in Greater Manchester 20162021 ‘Testing times to come? An evaluation of pathology capacity across the UK’ Introduction