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Pathology Best Practice Sorting Methodology
Share PrintOrlando VA Pathology Lab experienced a diagnostic error in the microscopic examination of pathology slides resulting in a serious adverse event to a veteran. This was secondary to a mix up of slides between cases obtained from two different veterans. This was facilitated by the lack of standardization in the distribution, sorting and filing of pathology slides. Following the implementation of our novel Pathology Best Practice sorting methodology that is 100% error proof, we have enjoyed 100% overall compliance and sustainment with an approximate 1.2 to 1.4 million dollars in both cost savings and avoidance.
Origin:
July 2022, Orlando VA Medical Center
Adoptions:
1 successful
Awards and Recognition:
Best Practice, National Enforcement Office, VACO Path & Lab Med, Institute of Industrial and Systems Engineers (IISE) , Best Practice, The Joint Commission
Recent Updates
Overview
Problem
Images
Pathology Office: Notice the slides folders (yellow arrows) randomly distributed all over the office with multiple folders lying on the desktop around the microscope. There is no way to distinguish between new (unread), consult, pending further studies or completed cases.
Another Pathology Office with slide folders (yellow arrows) scattered all over with no sorting or organization.
A third Pathology Office: Again, the yellow arrows point to slide folders that are scattered throughout the office with no clear sorting or designation. Notice how many slide folders, each belonging to a different veteran, are on the same desktop with the possibility of inadvertently mixing up or transposing one slide from one folder to another. Imagine a slide with cancer is transposed to another tray with a benign condition and the pathologist not paying full attention to this error. Imagine the pathologist had to be on leave and someone else had to cover and pick up the work in this mess of slide folders. Or imagine that a slide folder with yet incomplete studies is inadvertently placed under a stack of folders that are complete and filed in the archive by mistake, leaving the veteran with a missed diagnosis.
Pathology Hallway: Yellow arrow show the disorganized nature of the slide folders that are picked up and dropped off by the pathologists. Cases routinely get mixed up between pathologists. There is no way to clearly distinguish between new, completed and partially read pending additional study cases. Besides, the location of the shelf cabinet was obstructive to egress point with many employees having been injured while working on the shelf as someone opened the door hitting them accidentally.
Solution
2. Implementation of pre and post wall mounted bin sorting methodology for slide folder handoff, distribution and final disposition. Created labels on the color coded bins for clear identification and process adherence.
3. Removed excess ob ... 1. No more than one case belonging to one veteran is allowed to be on the desktop around the microscope at any time.
2. Implementation of pre and post wall mounted bin sorting methodology for slide folder handoff, distribution and final disposition. Created labels on the color coded bins for clear identification and process adherence.
3. Removed excess obstructive furniture.
4. Provided training for all staff on this new sorting methodology and monitored adherence by random audits. See more
Images
Pathology Office: No more than one case is allowed to be reviewed on the desktop around the microscope at any time. Zero chance of mix up or transposition of slides. All other cases, whether new or partially read pending additional studies are placed in color coded and labelled bins that are attached to the wall. This sorting methodology is immune from errors secondary to distraction or interruption and will not allow accidental filing of cases that are incomplete. In addition, pending cases can be easily picked up by another pathologist in the event of sickness or annual leave by the primary pathologist.
Pathology Office: Close up view of bins from top right to bottom right. 1. New Cases for Review = labelled blue bin; 2. New malignancy/Consults = Labelled red bin; 3. Pending cases/require additional studies/stains = Labelled yellow bin; 4: Cases returned after completion of additional studies/stains for further review = Labelled white bin, 5. QA/10% random review cases = Labelled black bin; and 6. All completed Cases = Labelled green bin
Pathology Hallway: Close up view of pick up and drop off bins as assigned to each pathologist by name: 1.) Newly processed cases for review = Blue bins; 2.) Cases returned for further review after completion of additional studies = White bins; and 3.) QA/10% random review cases = Black bins.
Pathology Hallway: Pathologists drop off all completed cases in the green bins for easy archival storage by the histotechnologists.
Results
2. Enhanced efficiency of pathology case review with more timely and accurate test results.
3. Increased patient safety with established error proof methodology upholding HRO ... 1. Error proof streamlined workflow: ZERO error in mix up of cases or transposition of slides from one case to another and ZERO error in the inadvertent filing of incomplete cases.
2. Enhanced efficiency of pathology case review with more timely and accurate test results.
3. Increased patient safety with established error proof methodology upholding HRO principles and promoting a Culture of Safety.
4. Markedly improved pathologist office space utilization.
5. Improved and efficient easy delivery and filling process as well as disposition of completed cases.
6. Increased employee safety by removal of obstructive hallway shelf cabinet and improved space. See more
Images
1 pathologist fall-out resulted in the 90% initial score for pathologist group, Fall-out occurred not from a lack of knowledge of Best Practice Process but due to lack of Buy-in. The Pathologist required Re-training to achieve 100% overall compliance for Pathologist. Process has continued to enjoy 100% compliance to date September 2023. There is over 80% percent increase in productivity and 1.2 to 1.4 million in direct cost avoidance with 100% sustainment compliance. The success of this new innovative process lead to creation of SOP (ANP-PATH-SOP-16 Pathologist Work Instructions) Creation and Implementation of Clinical Pathology Best Practice sorting methodology for consistent and error proof Standard work process.
- Complete 9 Box A3 of this new innovative Sorting Methodology. Pathology Best Practice Sorting Methodology A3, 9 Box
Files
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Implementation
Departments
- Quality Management
- Laboratory and pathology
Core Resources
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Risks and mitigations
| Risk | Mitigation |
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| Difficulty getting timely response and feedback from vendors | Have a good relationship with your logistic/Supply management team and bring them in early in your process. The cost associated with this project can be easily put on a purchasing card so no need for contracting. Also items needed for your project can be directly purchased from online through your logistics/Supply chain team. Use a vendor with fast shipment, preferable overnight shipment. |
| Initial staff push back against change | Change is never easy. Selling this innovation is accomplished by emphasizing the error proof and zero harm outcome. Essentially, the risk of mixing up case files and archiving incomplete cases by mistake is permanently eliminated. Besides, if a pathologist were to go on leave (sick, vacation, etc.), another pathologist can have the full confidence to pursue the work and provide optimal coverage. Additional benefits include increased efficiency, timeliness and standardization across the service. |
Contact
Comment
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Email beniah.nwankwo@va.gov with questions about this innovation.
About
Origin story
Original team
Dr. Fady Baddoura
Dr Fady Baddoura completed his Anatomic and Clinical Pathology residency and fellowship training in Hematopathology at Emory University in Atlanta, GA. While in training, he became interested in advanced diagnostic tools and basic research projects employing emerging molecular techniques, gaining further experience as a fellow in Molecular Pathology and a guest researcher at the Centers for Disease Control and Prevention (CDC). He pursued his professional career as a staff pathologist with clinical duties and funded research activities at the VA Western NY Health Care System at Buffalo before he transferred to the OVAHCS in 2015 and was appointed as the Chief of Pathology and Laboratory Medicine in April 2021. He is board certified in Anatomic and Clinical Pathology and Hematopathology, holding academic appointments as assistant/associate professor in Pathology at SUNY and full professor at the UCF College of Medicine. While in Western NY, Dr Baddoura built the VISN-2 referral center for Hematopathology, Flow Cytometry and Molecular Diagnostics, and is currently pursuing the same goal at the Orlando institution including a reference hub for Molecular Diagnostics employing Next Generation Sequencing for Cancer Precision Medicine, Pharmacogenomics and viral genomic sequencing. Dr. Baddoura’s main research interest is the role of Lymphoid Neogenesis in various disease entities including cancer and chronic rejection of transplanted organs. His work in transplantation has led to new discoveries, a recognition award and a patented methodology under development.
Dr. Beniah Nwankwo
Dr. Beniah (Ben) Nwankwo is a trained internist as well as extensive experience and expertise in Lean Six Sigma as a Nationally Certified Blackbelt and System Redesign. As a US Army Veteran who served with distinction receiving medals such as the National Defense Service medal and the Humanitarian service Medal, Dr. Nwankwo possess a strong zeal for Process Improvement and Organizational excellence in High Reliability (HRO) and Facilitation of a change culture for overall reliable exceptional and safe patient care. As a physician executive with 7 years of demonstrated success in academia, clinical practice, development, and medical affairs. Dr. Nwankwo has proven ability to lead teams, develop cross-functional synergy and deliver projects on time and within budget. Demonstrated excellence in strategic planning, project leadership, program management, outcomes research and rapidly absorbing and summarizing clinical data for development of Best Practice solutions.
Dr Jonathan Vasquez
Dr Jonathan Vasquez completed his Anatomic and Clinical Pathology residency and fellowship training in Cytopathology at University of Illinois in Chicago. He continued to advance his training in two subspecialties namely surgical pathology fellowship program at University of Iowa Hospital and Clinics and cytopathology fellowship program at Loyola University Medical Center for which he is board certified. He pursued his professional career as an anatomic pathology director at a private hospital in Illinois under the Hospital Sisters Health System. Subsequently relocated to Orlando VA Health System as a staff pathologist to assist in the startup of providing anatomic pathology service to veterans and provide clinical pathology test guidance to all providers. He holds an academic appointment as an assistant/associate professor in Pathology at University of Central Florida College of Medicine. He has published numerous peer reviewed articles and actively participates in the tutelage of medical students, medical residents, aspiring histotechnologists and pathology assistants in the world of surgical pathology. He continues to be a strong advocate of quality assurance and control management in anatomic pathology.
Practical, low cost and high yield process improvement initiative. Easy to adopt and easy to adapt to varied local situations.
Excellent way of organizing slides and slide trays. Easy to implement. We will surely try to implement this outstanding solution with tremendous positive impact on patient safety.
Strengths of this proposal:
1) A practical, simple and inexpensive solution to a problem that is found across all
Pathology practice environments ranging from VA to Academia to Community
Practice.
2) Easy to implement as suggested, but also easily modified if needed, to meet
unique workflow requirements at another VA lab.
3) A strong implementation strategy:
a) education and training of pathologists in the new workflow,
b) routine periodic monitoring to ensure a durable, sustained process, that
does not degrade over time.
I commend Dr. Baddoura and his team at the Orlando VA for developing and implementing this innovative process at the Orlando VA.
Night and day difference. The additional visual cue of the color coded boxes are a wonderful thought. I like how the boxes are setup nicely and take up very little room. Great way to incorporate the iCARE values!!
This is AMAZING!!!
Definitely best practice-- low cost, visually distinctive, great way to avoid confusion and lost of pathology slides
Thank you so much for the endorsement. Error proof, zero harm, efficient and cost-effective process. The return-on-investment comparative to the meniscal investment is truly incalculable. In addition to the proven benefits of patient safety, this process has the added benefit of improving staff productivity and job satisfaction. Thank you so much for your comments.