Benchmarking turnaround time in Pathology and Laboratory Medicine

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