Benchmarking turnaround time in Pathology and Laboratory Medicine, Program Director; College of American Pathologists, Spring Meeting, Boston, MA April 10, 2000 and Fall Meeting, Philadelphia, PA, October 21 2001
| Inter-Institutional Comparison of Frozen Section Turnaround Time | |
| RATIONALE:
CAP Laboratory Accreditation Program Inspection Checklist (1994) Question 08.1170
“the critical interval for preparing and having frozen sections ready for review as 15 minutes, measured from the time the specimen is received by the pathologist to the time the slide is available for interpretation” |
RESULTS:Laboratory Practices of Participating Institutions
Laboratory Practice % of Institutions
<300 Beds >300 Beds
Schedule FS N=506 N=148
Yes 68 57
No 32 43
Call FS from: N=502 N=148
OR, Other 96 97
Specimen arrives 4 3
Call FS to: N=503 N=146
Path Dept, Lab, 66 70
Pathologist/ staff 34 30 |
| OBJECTIVES
Measure intra-operative frozen section turnaround time Examine practice variables that influence frozen section turnaround time |
RESULTSLaboratory Practices of Participating Institutions
Laboratoary Practice % of Institutions
<300 Beds 300 Beds
Staffing (>1 resp.) N=507 N=148
Full time 91 100
Part time, Other 18 7
FS technical staff 34 30
Monitor FS TAT N=508 N=147
Yes 20 25
No 80 75
Cryoat temp alarm N=504 N=148
Yes 21 31
No 79 69 |
| MAIN OUTCOME MEASURES
Individual Benchmark
–Aggregate 90% FS (receipt to report) block completion time Institutional Benchmark
— Percentage of outlier FS block TATs |
RESULTS Demographic Characteristics of Participating Institutions
Demographic Characteristic % of Institutions
<300 Beds >300 Beds
Hospital location
City 50 87
Suburban, Rural 50 13
Institution type
Private, nonprofit 68 57
Priv. profit, Gov’t 32 43
Teaching program 16 75
JCAHO accred. 79 69
CAP accreditation 78 77 |
| STUDY DESIGN
Prospective FS TAT / 4 months
30 inpatient cases / 4 specimens/case
Questionnaires profiling FS practice characteristics |
RESULTS Frozen Section Block Turnaround Time Performance by Individual Pathologists (Minutes)
Expressed in Percentiles N=32,868 FS Blocks
10th 25th 50th 75th 90th
4 7 10 15 20 |
| STUDY DESIGN — (Aggregate data) Record for each case:
Turnaround time Number of blocks
Reason for FS request Tissue type
Ancillary procedures Technical problems
#/type personnel preparing FS Wait for the tissue
# pathologists examining FS Simultaneous FS |
RESULTS: Frozen Section 90% Block Turnaround Time Performance by Institutions (minutes) Expressed in Percentiles
Percentiles
Bed Size N 10th 25th 50t 75th 90th
<150 305 12 15 17 21 25
151-300 201 12 15 18 21 26
>300 147 13 15 20 24 30
All 695 12 15 18 22 26 |
| PARTICIPANTS: 700 institutions: North America (667), Australia (12), New Zealand (1), United Kingdom (3), Hong Kong (1), Mexico (1),Norway (1) | RESULTS: Percent of Outliers
Aggregate 8.3%
Institutional 30% |
| STUDY DESIGN — Institutional Data
Demographics Surg. path./FS case volumes
Staffing levels FS scheduling
FS communication Travel time to FS area
Cryostat features FS TAT goals
Freezing & staining techniques |
RESULTS Percent of FS Block Turnaround Time Outliers Expressed in Percentiles
Bed Size Percentiles
10th 90th
<300 0 % 20%
>300 0 % 26% |
| Inter-Institutional Comparison of Frozen Section Turnaround Time | |
| RESULTS: Aggregate FS Block Completion Times (Minutes) and Number of Blocks Prepared /Specimen by Several Tissue Types(N=32 ,659 Blocks / 24,801 Specimens)
Tissue % Specs Blocks/Spec. Block TAT (Mins)
1 2 50t 90th
Skin* 21 61 39 8 18
Breast* 17 90 10 11 19
Lymph* 13 83 17 11 20
Oral^ 6 87 13 11 26
CNS^ 3 92 8 12 23
(ALL 100 83 17 10 20)
* Most common tissue types requested for FS
^ Tissue type with longest 90% block completion times |
RESULTS Effect of Procedure Variables on Percentage of Outlier FS Block TATs Procedure (%)
Simultaneous FS Retrieve slides
No 6 8
Yes 13 13 RESULTS:Waiting for Frozen Section Specimens to Arrive
7.9% of all FS blocks examined
Less likely to wait if scheduled FS (47.1% vs 56.2%)
20% of blocks required waiting if FS called to:
Central laboratory (26.4%)
Surgical Pathology Dept. (13.0%)
Pathologist directly (9.4%) |
| RESULTS: Aggregate FS Block Completion Times (Minutes) and Number of Blocks Prepared Per Specimen, by Most Common Reasons for FS Request N=24354)
Reason % of Specs Blocks/Spec. FS TAT (Min)
1 >2 50th 90th
10 malignancy 52 85 15 10 20
Margins 18 67 33 9 20
Mets 13 84 16 11 20
Interest surgeon 5 89 11 11 20
(ALL 100 83 16 10 20) |
RESULTS:Practice variables not contributing to TAT outliers
Scheduling of FS
Travel times to FS area
Cryo. maintenance
Surgical/FS case loads
Method of FS result communication
Origin/destination of FS request
Staining or freezing techniques
Cryostat temperature alarms
Monitoring of FS TAT |
| RESULTS: Outlier TAT’s more likely to occur when:
> one pathologist participated in diagnosis
Residents/medical students participated in procedure
Pathologist had to retrieve/review previous slides
Simultaneously FS cases
Deferreddiagnosis
Technical problems occurred during the procedure |
RESULTS:Procedures not contributing to TAT outliers
Inking margins
Making touch preps
Obtaining history
Taking tissue for cultures |
| RESULTS Effect of Personnel Variables on Percentage of Outlier FS Block TATs (%)
# pathologistsis
One 7.5
Two 12.5
Three 21.6
Resident(s) assisted Med stdnt(s) assist
Yes 15.8 12.7
No 7.3 8.3 |
RECOMMENDATIONS
Disseminate findings
Set FS TAT goal
Track TATs outliers
Retrieve previous case material
Scheduling of frozen section
Routine cryostat maintenance
Route requests to surgical pathology |
| Inter-Institutional Comparison of Surgical Pathology Complex Specimen Turnaround Time | |
| OBJECTIVES
Determine intra-laboratory (analytic) TAT benchmark
Examine practice variables that influence TAT DEFINITION: Intra-laboratory (analytic) Turnaround Time–Specimen accession to final report verification DEFINITION:Complex Specimen-CPT codes 88307,88309 DEFINITION: Routine Case-Standard tissue processing & histopathologic evaluation DEFINITION: Special Handling Case-Prolonged fixation, fat clearing, additional tissue, recuts, levels, re-embedding, reprocessing, special stains, de-calcification, outside consultation, specimen rejection |
RESULTS: Mean Percent of Complex Specimen Report Completion Within 2 Working Days
by Occupied Hospital Bed size
Bed size Participants (%) %Reports
Routine Cases
0-150 128 (27.2) 92
151-300 178 (37.9) 94
301-450 91 (19.4) 87
451-600 39 ( 8.3) 81
>600 34 ( 7.2) 81
Special Handling Cases
0-150 120 (26.5) 63
151-300 174 (38.5) 66
301-450 87 (19.2) 56
451-600 38 ( 8.4) 44
>600 33 ( 7.3) 41 |
| EXCLUSIONS FROM STUDY:Work delegated to specialists (dermatopathologists, hematologists, neuropathologists)
DESIGN: Track days from accession to sign-out, 30 Days, 4 Months DESIGN:Practice Variables
Specimen volume
Staffing
Reporting practices
On site/off site services
Departmental TAT goals |
RESULTS: Mean Percent of Complex Specimen Report Completion Within 2 Working Days
by Personnel Dictating Gross
Person responsible Participants % Reports
Routine Cases
Pathologist only 283 94
Resident only 39 72
PA 32 92
Combo 126 86
Special Handling Cases
Pathologist only 273 66
Resident only 37 32
PA 30 62
Combo 122 53 |
| DESIGN: Demographics
Hospital bed size
Hospital location
Teaching status/residency program
Laboratory accreditation RESULTS:
489 Laboratories
14,298 Complex surgical specimens |
RESULTS Mean Percent of Complex Specimen Report Completion Within 2 Working Days by Resident Participating in Microscopic Sign-out
Resident Involved Participants % Reports
Routine Cases
Yes 91 75
No 386 94
Special Handling Cases
Yes 88 37
No 386 65 |
| RESULTS: Complex Specimen Report Completion
Routine and Special Handling Cases
Working Day Cumulative Percent
0 .4
1 56.3
2 80.5
3 90.7
4 95.2
5 97.2
10 100.0 |
RESULTS: Practice Variables Having Minimal, Uncertain or No Effect on Complex Specimen Turnaround Time
Microscopic Dictation
Mechanism of Finalizing/Transmitting reports
Number of physicians (<5) involved in case
Budgeted Histotechnicians
Budgeted Transcriptionists
Institutional TAT goals |
| Inter-Institutional Comparison of Surgical Pathology Complex Specimen Turnaround Time | |
| RESULTS: Mean Percent of Complex Specimen Report Completion Within 2 Working Days by Availability of Slides
When slides ready Participants (%) % Reports
Routine Cases
Before 8 AM 41 ( 8.6) 94
8 – 10 AM 178 (37.2) 95
10 AM – Noon 195 (40.7) 88
Noon – 2 PM 56 (11.7) 78
After 2 PM 9 (1.9) 82
Special Handling Cases
Before 8 AM 42 ( 9.1) 68
8 – 10 AM 168 (36.4) 69
10 AM – Noon 185 (40.1) 59
Noon – 2 PM 57 (12.4) 33
After 2 PM 9 (2.0) 42 |
RECOMMENDATIONS: Performance benchmarks for complex specimen tat of reports completed
Working day Overall Routine Special Handling
1 56 73 21
2 81 91 58
3 91 97 78
4 95 99 88 RECOMMENDATIONS
Analyze elements of production
Analyze pre- and post- analytical process
Intermittently monitor |
| Surgical Pathology Routine Biopsy Specimen(1992) | |
| STANDARD ADDRESSED: 08.0760 CAP Lab Accreditation standard for Anatomic Pathology–Are routine reports completed in 2 working days?
Prospective evaluation of intra-laboratory (analytic) TAT-specimen accession to report completion
30 routine biopsies 3 month period
525 labs 15, 725 biopsies EXCLUSIONS:
prolonged fixation recuts, levels
re-embedding reprocessing
special stains decalcification
extra-departmental consultations |
RESULTS: Routine Biopsy TAT-median days to report completion by working day
Practice Variable Percentile Ditribution
10th 50th 90th Mean
All labs 2 1 1 1.2
Resident involved in signout 3 2 1 1.8
Bed size >600 3 1 1 1.5
Slides by 12-2 p.m 3 1 1 1.6
Lack of histotechs/transcrip 2 1 1 1.4
No lab TAT Goal 2 1 1 1.4 |
| Surgical Pathology Routine Biopsy Specimen Turnaround Time in Small Hospitals (1994) | |
| STUDY SCOPE:
Prospective 3 months
Preanalytic, analytic, postanalytic TAT
Specimens coded 88302, 88304, 88305
20 routine diagnoses and 20 action-alert diagnoses
157 labs 5,384 Biopsies |
RECOMMENDATIONS: Routine biopsy diagnoses
Working Day % Reports Completed % of Reports Received
1 59 23
2 87 57
3 95 78 |
| DEFINITION: Routine diagnosis–Definitive diagnosis that describes a disease process associated with a low morbidity and that does not require immediate follow-up or diagnostic or therapeutic action | Contributors to shorter TAT:
On sitet histo processing/pathologist evaluation
Increased pathologist/histotech staffing
Later tissue accession times
Report transcription Sundays
Telephone reporting |
| DEFINITION: Action-alert diagnosis-
Positive for cancer
Suspicious, inconclusive for cancer
Unsatisfactory for evaluation |
Contributors to longer TAT:
Smaller bed size (24-100)
Delayed report sign-off
Charting of reports by non-pathology staff
Part time requesting clinicians
Off-site histology services |
| RESULTS: No significant difference in TAT between routine and actin-alert diagnosis at either sign-off or hard copy receipt time points TAT Percentile Results
10th 50th 90th Day
3 1 1 sign-off TAT
4 2 1 hard copy TAT |
|
Inter-Institutional Comparison of
Frozen Section Turnaround Time
RATIONALE
CAP Laboratory Accreditation Program Inspection Checklist (1994) Question 08.1170
“the critical interval for preparing and having frozen sections ready for review as 15 minutes, measured from the time the specimen is received by the pathologist to the time the slide is available for interpretation”
OBJECTIVES
Measure intra-operative frozen section turnaround time
Examine practice variables that influence frozen section turnaround time
MAIN OUTCOME MEASURES
Individual Benchmark —
Aggregate 90% FS (receipt to report) block completion time
Institutional Benchmark —
Percentage of outlier FS block TATs
STUDY DESIGN
Prospective FS TAT data collection
Thirty elective inpatient cases
Four specimens/case
Four month study period
Questionnaires profiling FS practice characteristics.
STUDY DESIGN — Aggregate data
Record for each case:
Turnaround time
Number of blocks
Reason for FS request
Type of tissue examined
Ancillary procedures performed
Number and type of personnel preparing FS
Number of pathologists examining FS
Wait for the tissue to arrive in FS area
Technical problems
Simultaneously occuring FS
Deferred FS diagnosis
STUDY DESIGN — Institutional Data
Demographics
Surgical pathology/frozen section case volumes
Pathologist staffing levels
Elective FS case scheduling procedures
FS request and FS result communication procedures
Pathologists travel time to FS area
Tissue freezing and staining techniques
Cryostat features
FS TAT definitions and FS TAT goals
PARTICIPANTS: 700 institutions
North America (667)
Australia (12)
New Zealand (1)
United Kingdom (3)
Hong Kong (1)
Mexico (1)
Norway (1)
RESULTS
| Demographic Characteristics of Participating Institutions | ||
| Demographic Characteristic | Percentage of Institutions, by Bed Size | |
| <300 Beds
(N=513) |
>300 Beds
(N=149) |
|
| Hospital location | ||
| City | 50 | 87 |
| Suburban, Rural, Other | 50 | 13 |
| Institution type | ||
| Private, nonprofit | 68 | 57 |
| Priv. profit, Gov’t, Other | 32 | 43 |
| Teaching program | 16 | 75 |
| JCAHO accreditation | 79 | 69 |
| CAP accreditation | 78 | 77 |
RESULTS
| Laboratory Practices of Participating Institutions | ||
| Laboratory Practice | % of Institutions | |
| <300 Beds | >300 Beds | |
| Schedule elective cases in advance | (N=506) | (N=148) |
| Yes | 68 | 57 |
| No | 32 | 43 |
| Call requesting FS made from: | (N=502) | (N=148) |
| OR, Other | 96 | 97 |
| None: specimen arrives in lab | 4 | 3 |
| Call requesting FS directed to: | (N=503) | (N=146) |
| Surg Path Dept, Lab, Other | 66 | 70 |
| Pathologist/FS technical staff | 34 | 30 |
RESULTS
| Laboratory Practices of Participating Institutions | ||
| Laboratory Practice | % of Institutions | |
| <300 Beds | >300 Beds | |
| Pathologist staffing (>1 response) | (N=507) | (N=148) |
| Full time | 91 | 100 |
| Part time, Other | 18 | 7 |
| Pathologist/FS technical staff | 34 | 30 |
| FS TAT monitored in laboratory | (N=508) | (N=147) |
| Yes, within the past year | 20 | 25 |
| No | 80 | 75 |
| Cryostat has a temperature alarm | (N=504) | (N=148) |
| Yes | 21 | 31 |
| No | 79 | 69 |
RESULTS
| Frozen Section Block Turnaround Time Performance by Individual Pathologists (Minutes)
Expressed in Percentiles |