HIDDEN DANGER IN PATHOLOGY

Dr. Raymond MaungChair (Workload & Workforce Committee)

Increasing Pathologist Workload

Standard of care Reports Technology “onomics”▪ Diagnostic▪ Prognosis▪ Therapeutics ▪ Individual and family management

Quality Assurance

Report 1996 - Melanoma

Report 2006 - Melanoma

Report 2014 - Melanoma

Technology

Procurement to Sign-out Current standards

Immunohistochemistry Cytogenetics FISH, CISH Flowcytometry Ploidy studies

“onomics” proteinomics transcriptnomics genomics

QA - Cameron’s Report

“Time for QA be considered when determining the number of pathologists and oncologists required for each institution so that physicians do not have to choose between day-to-day tasks and participation in QA process.”

“Pathologists and oncologist should be required to participate in such (QA) rounds as a condition of continued employment with the regional health authority”

QA - Creaghan’s Report

“The problem arose because there was no quality assurance protocol in place for the laboratory and consequently, no operative standard quality control mechanisms.”

Recommended a number of QA processes as per national and international pathology organizations.

QA - Windsor Regional Hospital Report

“All pathologists working in Windsor adopt the Quality Assurance Program for Pathology developed by the Chief of Pathology which includes peer assessments, auditing and correlational analysis. Appropriate laboratory physician and administrative resources should be allocated to support the Program.”

QA - The Royal College of Pathologists Australasia (RCPA)

“Foregoing participation in quality assurance activities should not be considered an acceptable option by pathologists or employers - quality assurance of their work is a mandatory requirement for pathologists and it is one of their core elements of responsibility for ensuring effective patient care.”

Unique – Pathologist’s Workload DO NOT control our workload volume

determined by users of laboratory services Most pathologists are on salary or contract

with NO clause in their contract regarding appropriate workload

DO NOT have inherent limiting factor on workload Others: OR availability, office hours, CT time

availability Rate limiting factor in pathology is the

pathologist ability to sign out the case

The Enemy - Pathologists We are our own worse enemy

In most departments, all the work processed is distributed to the pathologists

Most of us feel obligated to complete the work when it lands on our desks – thus no dysfunction (wait time or patient complaints)

IMAGINE if there were “wait times” in pathology▪ patients waiting 4 weeks for breast or prostate biopsy results▪ patient informed 6 weeks after the biopsy that he has

melanoma or colonic carcinoma▪ oncologic management is delayed due to incomplete pathology

consult Most patients do not know that “pathologist” exist until

there is dysfunction.

Reality Check

Administration understands only “dysfunction”

Without obvious visible dysfunction in pathology, resources flow to more visible dysfunctions, namely to shorten wait time

Attention only when “dysfunction” occurs – various commissions in the recent past.

Laboratory and Pathology though essential for final diagnosis, follow up and management – most including most physicians do not know what a pathologist really does.

Study - The Royal College of Pathologists Australasia (RCPA)

Indicators of Quality and Safety1. an increase in turnaround time; 2. not always completing QA; 3. quality compromises; 4. patient care compromised; and 5. health and well being of

pathologists being compromised

Study – RCPAQuality and Safety by hours worked

None=>4

=>3

=>2

=>1

Fatique and Potential for errorsDr. Matthew B. Weinger (Director, Center for Research &

Innovation in Systems Safety)1. A rare, but very salient signal has to be detected:

desmoplastic melanoma2. Multitasking and prioritization are key elements of

work: work disrupted by technologists or clinicians 3. There is a time gap between when information

becomes available and when it has to be used: relevant clinical information not available when reviewing slides.

4. Creative thought is required: when facing a lesion unfamiliar

Studies - Hours worked per week Studies show that working overtime or

working more than 40 hours in a week was associated with a statistically significant increase in the risk of making an error.

working more than 40 hours per week (overtime), working extended shifts (more than 8 hours), and working both extended shifts and overtime can have adverse effects on worker health.

Studies - Long Shifts

Physicians are also noticed to have deterioration in cognitive performance with long shifts.

Accident rates increases with the length of work , with accident rates rising after 9 hours, doubling after 12 consecutive hours, and tripling by 16 consecutive hours of work.

Studies - Physicians

Study on 34 pediatric residents showed that following a night of heavy call was quite similar to performance after drinking alcohol. Reaction times were slowed, errors of commission increased 40%, and on simulated driving test, lane variability and speed were significantly increased after a night of heavy call

Interns made 35.9% more serious medical errors during the traditional schedule (extended hours and every third night call) than during the intervention schedule (restricted schedule that reduced work shifts to 16 hours).

Studies - Health Impact

Meta-analysis of 21 studies showed that there is a link between hours of work and ill health, and that working long hours can be detrimental to health of an individual and his/her family.

Analysis of 27 empirical studies showed that long work hours were associated with adverse health effects (cardiovascular disease, diabetes mellitus, disability retirement, physiological changes, and health-related behavior).

Studies - Cost of Fatique

Two significant nuclear power plant accidents (Three Mile Island and Chernobyl) and the environmentally disastrous grounding of an oil tanker (Exxon Valdez) occurred at night, during early morning hours when vigilance is at its lowest.

Fatigue-related problems are believed to cost the United States an estimated $18 billion dollars per year in lost productivity and accidents. More than 1,500 fatalities, 100,000 crashes, and 76,000 injuries annually are attributed to fatigue-related drowsiness on the highway.

Reality Checkpopulation served / practitioner

1998 2008%

changeFamily Physician 1,060 994 +6.2%Medical specialists 1,635 1,529 +6.5%Surgical specialists 3,912 4,048 -4%

Lab. Physicians 21,311 21,686 -1.8%

Pathologists 27,612 27,991 -1.4%

All physicians 538 512 +4.8%

Reality Checkpopulation served / practitioner

Population / per lab. physician

1998 2008 % change

Saskatchewan 19943 26251 -31.6%

BC 18498 19644 -6.2%

Ontario 23744 24784 -4.4%

Quebec 18276 18753 -2.6%

Newfoundland 16769 16967 -1.2%

Canada 21311 21686 -1.8%

Population / per pathologist

1998 2008 % change

Saskatchewan 23653 31024 -31.2%

BC 22322 23636 -5.9%

Ontario 27587 28418 -3.0%

Quebec 33844 37237 -10%

Canada 27612 27991 -1.4%

Reality Check Clinicians / per Lab.Physician

1998 2008 % change

Saskatchewan 29 41.5 -43%

Newfoundland 27.9 36 -29%

BC 34.7 39.3 -13.30%

Alberta 38.7 43.7 -12.90%

Quebec 37.6 40.1 -6.60%

Ontario 41.5 43 -3.90%

New Brunswick 40.1 40.3 -0.50%

Canada 38.5 41.4 -7.50%

Reality Check

high portion of departments were understaffed (74%, varies from -11 % to -66.67%)

In BC, the government insisted on a workload volume 18.75% and in Quebec 67.46% higher than the recommended L4E value.

Recently there were 3 major and many minor “mishaps” in pathology throughout Canada.

Reality Check - Comparison

Population /provider

Australia (pathologist)

17,829

Canada (Lab.Phy.) 21,686

Canada (pathologist) 27,991

US (pathologist) 19,231

CAP-ACP 2014 update

CAP-ACP has updated the Workload model includes QA

activities Simplified so that

learning 9 rules will allow to code for most specimens

Academia ▪ Education & training▪ Scholarly work

(research) Administration

Model flexible to meet the needs for most departments a (all): Gross +Micro in

surgicals, unscreened slides in cytology

m (micro): Micro only in surgicals, screened slides in cytology

s (special): Consults, Reviews, Special studies, Correlations, etc.

e (education): Working with trainees

Spreadsheet to implement the model available

CAP-ACP 2014 update

Comparable to other models Comprehensive: includes QA activities, academia

and administration Flexible: from community to academic centers Fair

Public: provides efficient and effective pathology services

Funding agencies: the recommended workload is higher than other models and integrates QA work as recommended by various commissions and agencies

Providers: provides a safe workload enabling to produce best pathology services for clinicians and the public

CAP-ACP 2014 update

Endorsed by CAP-ACP “Living” document with input from

pathologists throughout Canada Extensive experience

ONE CANADIAN MODEL will Allows for comparison between departments and

provinces Allow pathologists to negotiate with Heath

Authorities more effectively – workload As QA activities are built into the model, essential

QA activities will be recognized (as recommended by the commissions) as part of the workload

Conclusion

“given that medical personnel, like all human beings, probably function suboptimally when fatigued, efforts to reduce fatigue and sleepiness should be undertaken, and the burden of proof should be in the hands of the advocates of the current system to demonstrate that it is safe.”

Hidden danger in Pathology

Questions ? Comments ?