Clinical Pathologist Procedure Pathologist Pathologist Analytic/Diagnostic Quality Plan

Clinical Pathologist Procedure Pathologist 001.01 Pathologist Analytic/Diagnostic Quality Plan Final Approval: August 2010 Effective: August 2010 Next Review Date: August 2014 List all stakeholder(s) and dates of approval: Stakeholder Name(s): Mark Magilner, MD Date: 8/10 Reviewed Revised Stakeholder Name(s): Clark McDonald, MD Date: 8/10 Reviewed Revised Stakeholder Name(s): Mark Magilner, MD Date: 12/11 Reviewed Revised Stakeholder Name(s): Mark Magilner, MD Date: 8/12 Reviewed Revised Stakeholder Name(s): Magilner, MD Date: 9-05-13 Reviewed Revised Describe briefly the most recent revision made to this policy, procedure or protocol & why: 12/11 This is an editorial revision for minor editing and formatting changes. (previously revised 2/10 by CEM) 12/11 Added prospective activity: Pathologist participation in PT testing. 12/11 Title Change to "Analytic/Diagnostic " Purpose/Policy Statement: The goals of the Pacific Pathology Associates, Inc. (PPA) Quality Plan are to ensure accuracy, completeness, and timeliness of all the reports generated by the Pathologist members, by utilizing the principles of a Performance Improvement Program. Additional aspects of quality addressed in this document include National Patient Safety Goals and Pathologist availability/responsiveness for patient / client consultation and communication. The Quality Plan employs both prospective activities as well as retrospective methods of review and includes the essential elements of Peer Review. This policy primarily focuses on Pathologist interpretation. Aspects of technical specimen processing are covered elsewhere in the PPA procedure manuals. Definitions: POLICY CONTENT KEY POINTS OF EMPHASIS: The goals of the Pacific Pathology Associates Performance Improvement Program are achieved by implementation of policies, procedures and reviews centered on each of the following areas: 1. Prospective activities: a. Utilization of Cancer Reporting Templates b. Intradepartmental Consultations c. External Consultations d. Self-assessment programs and Continuing Medical Education e. PT Testing participation 2. Retrospective activities: a. External Reviews (Inter-Institutional Peer Reviews) b. Interdepartmental conference/post sign-out reviews c. Pathology case directed and random reviews d. Intraoperative Consultation Diagnosis accuracy 3. Pathology and Non-Gyn case turnaround time a. Including intraoperative consultation (frozen section) turnaround time TRACKING SYSTEM AND REPORTING PROCESS: The CoPath system contains a secure section specifically designed for tracking Quality Assurance activities. Whenever possible, this is the preferred method of documenting and tracking QA activities. Page 1 of 10

The results of the documentation and tracking activities for the group as a whole are reviewed semi-annually at the PPA pathologist s meeting for discussion. Individual specific data will be provided separately in a confidential fashion. Wherever possible, the data will be presented in a graphical format comparing collected data to the group mean and goal. In addition, selected data is provided to various credentialing bodies as needed. Data are provided to the Credentialing Committees of the various hospitals as requested and in accordance with the Bylaws of each facility. The data may also be used to satisfy any contractual quality assurance in accordance with the terms of the contract. COMPEHENSIVE CASE REVIEW: The Comprehensive Case Review is the process employed for PEER review and case issue resolution. This process is initiated for any case identified as having a major disagreement in diagnosis, either on internal review or external review, where there is real potential of serious impact on patient care. Actions as a result of this review process can either be immediate or on going. The triggers for a Comprehensive Case Review are delineated in the appropriate places throughout this document. Various methods of review may be employed and can range from simple review of the case material with issuance of addendum s or amendments as needed to utilization of an outside consultant for discrepancy resolution. Outside consultation is compulsory in those cases where there is a disagreement in diagnosis among the reviewing pathologists. In any event, the treating clinician must be notified immediately that there is a diagnosis in question. Any case that requires a Comprehensive Case Review is processed as follows: 1. All diagnostic material is pulled from the files and all reports are gathered 2. The material is initially reviewed by the PPA Quality and Compliance Officer 3. If a discrepancy is confirmed, the case is reviewed with the pathologist of note. 4. An amended report is issued and the responsible treating physician is notified. 5. The actions are documented in the QA section of the CoPath system. 6. If the primary pathologist on the case is the PPA Quality and Compliance Officer, the review and documentation is carried out by the Section Chief or designee. 7. If a systems issue is identified, a formal PI review is initiated. 8. Cases with potential legal implications are reported to the liability provider that was in effect at the time of the discrepancy. UTILIZATION OF CANCER REPORTING TEMPLATES The utilization of templates in the reporting of cancer biopsies and resections is recognized as a best practice in the conveyance of information needed for the development of treatment strategies. The pathologists of PPA incorporate these templates into reports wherever feasible. The templates used for cancer reporting purposes are taken wholly or in part from the recommendations provided by the College of American Pathologists (CAP). These templates may be modified from time to time to include information deemed valuable to the treating physicians within our patient catchment area. Templates for all major organ systems will be employed as they become available and recommended by CAP. The standard staging protocol will be based on the TNM classification schemes as designed by the AJCC and adopted by the NCCN guidelines. Additional staging information such as GOG and WHO will be incorporated as appropriate for our patient population and study protocols being utilized. The templates will be reviewed annually and any updates provided by CAP will be incorporated. INTRADEPARTMENTAL CONSULTATIONS Second opinions sought on difficult cases, controversial cases, and cases that will lead to a major surgical intervention are a recognized way of reducing diagnostic errors. The pathologists of PPA have developed a prospective system by which all difficult, controversial, and otherwise problematic cases can be presented to additional pathologists for consultation and discussion before a final diagnosis is rendered and the case is signed out. In addition, it is the policy of PPA that all new malignancy diagnoses that have the potential to lead to a treatment intervention are reviewed by at least one additional pathologist. The pathologists of PPA believe that intradepartmental consultations that involve multiple pathologists provides a forum of discussion of patient care issues that ultimately leads to uniformity of diagnosis, continuous improvement of processes Page 2 of 10

and diagnostic skills. To this end, a daily Case Review Conference is held in which all pathologists are invited to attend and participate. Presentations of cases that have educational value or discussion points are encouraged. Intradepartmental Consultation must be obtained in the following situation: 1. New malignancy diagnosis which has a high likelihood of being followed by a definitive surgical procedure. An example would be a prostate biopsy that will be followed by a radical prostatectomy. 2. Exceptions are cases that have low surgical risk such as basal cell carcinomas of the skin, cases where the original diagnosis was made elsewhere and we first saw the malignancy on a surgical specimen from a definitive procedure, or the definitive procedure was performed for diagnosis. Intradepartmental Consultation should be considered, in the following situations: 1. Problem-prone cases: a. As defined by personal experience b. As defined by local group experience c. As defined by a clinician d. As defined by the literature 2. Cases suggested for review by clinicians 3. Cases suggested for review by patients 4. Rare disorders that have clinical importance 5. Newly implemented procedures or new specimen types 6. New pathologist until competency is proven 7. Problem-prone pathologist until competency issues have been resolved 8. Cases of particular interest Note: Cases selected for intradepartmental consultation can be reviewed either by a selected pathologist or multiple pathologists or presented at the daily Case Review Conference. 1. The material presented should include all pertinent microscopic slides, a summary of the clinical data, and when indicated, gross specimen descriptions or gross photographs, and x-rays. 2. The case can be reviewed by individual pathologists or at the Intradepartmental Case Review Conference and then discussed. 3. Each case getting an Intradepartmental Review will be documented by the pathologist in the QA component of the CoPath system as outlined below: INTRADEPARTMENTAL REVIEW- Use for cases shown to other pathologist either individually or at conference, not new malignancies. DEFAULT-AGREE SECOND REVIEW OF NEW MALIGNANCIES- Use for second review of new malignancies no matter how shown, conference, individual pathologist, etc. DEFAULT-AGREE 4. If disagreement among pathologists is encountered, external consultation should be sought. 5. All cases reviewed by another pathologist in consultation or at conference should be so identified by recording the consultation in the final report if the pathologist in charge of the surgical pathology case determines that the results of the intradepartmental consultation provides relevant information. EXTERNAL CONSULTATION PPA recognizes that some cases pose particular diagnostic difficulty and external consultants with particular specialty expertise are available for case review and second opinions. The use of these consultants is strongly encouraged in order to provide appropriate patient care. External review of cases by specialist pathologists should be considered on the following: 1. Difficult cases with limited or equivocal material in which the diagnosis has clinical impact and there is significant risk in obtaining additional tissue. 2. Rare or unusual lesions that have clinical importance. 3. Problem-prone cases a. As defined by personal experience Page 3 of 10

b. As defined by local group experience c. As defined by a clinician d. As defined by the literature 4. A case in which internal disagreement exists that has major therapeutic or prognostic impact. 5. Cases in which essential confirmatory ancillary techniques are not available at our processing facility. 6. Cases where an external consultation would prove educational. 1. The primary pathologist on the case designated for external review assumes the responsibility for all aspects of the review process. 2. A preliminary diagnosis should be issued stating the differential diagnostic possibilities and a conversation with the primary clinician is recommended. 3. All relevant case material should be sent to the consultant for review. Re-cut stained slides or unstained slides are the preferred material if these are felt to be representative. Original material can be sent if necessary. Original paraffin blocks should not be sent unless deemed critical to the external evaluation and patient care. If original material or paraffin blocks are sent, a written request for return of the material is also sent. 4. A consultation letter should be dictated by the originating pathologist and sent with the case material along with a copy of the preliminary report, pertinent radiographic or clinical information and any required consultation request forms. 5. A pathologist must review the material for adequacy prior to send-out. 6. Consultation results should be made available to the principle clinicians and an amended report is added to the preliminary report, which includes the external consultant s interpretation and the originating pathologist s final diagnosis. SELF ASSESSMENT PROGRAMS, CONTINUING MEDICAL EDUCATION, PROFICIENCY TESTING (PT) PPA recognizes that continual improvement in diagnostic skills is tantamount to providing exceptional patient care and clinician consultation. The pathologists therefore participate in a variety of activities designed to improve performance. These activities include but are not limited to participation in External Self-Assessment programs, Conference participation, and Proficiency Testing as required. POLICY: External Self Assessment Programs 1. All pathologists are enrolled in an accredited Self-Assessment program for Anatomic Pathology, Hematopathology, and Cytology. The Clinical Pathology portion is required for those pathologists involved in the clinical portion of the laboratory and is optional for all the other pathologists. 2. Each pathologist reviews survey material either individually or in a group setting. 3. The survey results and discussions are reviewed by each individual pathologist as they become available. 4. The comparative survey results are kept with the survey material as part of the PPA Performance Improvement documentation. Conference Participation 1. All pathologists are encouraged to participate in locally sponsored educational seminars. 2. Pathologists are required to attend at least one comprehensive or specialized educational conference per year. 3. Any educational material obtained from attended conferences should be shared with the other pathologists. Proficiency Testing All pathologists will participate in the appropriate required proficiency testing and will be subject to the terms of successful completion as delineated by the testing body. INTERINSTITUTIONAL REVIEW Internal quality can be evaluated by the degree of diagnostic agreement among cases that have been sent to other institutions for various reasons. These represent cases that would not normally be sent for diagnostic purposes and are usually: 1. At the clinician s or patients request 2. The patient is being treated elsewhere 3. The case has been entered into a study Page 4 of 10

4. Any other reason for second opinion POLICY: It is the policy of PPA to supply material to outside institutions for review upon request. 1. The Pathology office staff will obtain a copy of the report(s) and pull the slides from the storage files. The request and material is presented to the pathologist of note on the case for review along with the Send-Out Case form. Another pathologist may review the material if the pathologist of note on the case is unavailable. 2. The pathologist will review the material and determine if the original material or re-cut material should be sent and which slides are appropriate. The pathologist will review any re-cut material for adequacy and tissue representation prior to send-out approval. 3. The office support staff will mail all authorized material to the designated consultant. 4. The Quality and Compliance Officer or designee will initially review returned consultation reports along with the original report(s). Correlation will be ranked according to their effect or potential effect upon patient care and the review will be entered into the QA section of the CoPath system using the following classification: IR1 Agreement between the reviewer and the original report. IR2 Minor differences in terminology not deemed to be clinically significant. IR3 Disagreement with some, but not significant, consequences for patient care. IR4 Major disagreement with potential serious impact on patient care. 5. All category 4 cases will trigger an immediate Comprehensive Case Review. 6. Returned consultation reports will be distributed to the pathologist of note for review and then distributed to the clinician(s) and the Health Information Management department. 7. The pathologist of note summarizes the consultant s review and interpretation and generates an addendum or amended report as deemed necessary. 8. Disagreements with the consultant s interpretation by the original pathologists (except IR 4 cases) should be resolved either by additional intradepartmental review or additional external consultant review. This should also be documented as an addendum or amended report. INTERDEPARTMENTAL CONFERENCE/POST SIGN-OUT REVIEW PURPOSE: Interdepartmental Conferences: To monitor the degree of agreement between the final diagnosis as portrayed in the pathology report (surgical, cytology, or autopsy) and the consensus reached at the interdepartmental conferences in which the case is presented. Interdepartmental conferences include conferences such as Tumor Board, Cancer Conference, Perinatal M&M conference or any interdisciplinary or multispecialty conference where pathology is reviewed post-sign out. Post Sign-out Review: To monitor the degree of agreement between the final diagnosis as portrayed in the original pathology report (surgical, cytology, or autopsy) and the reviewing pathologist. This includes cases reviewed internally for any reason. 1. Pathologists who review and present cases at interdepartmental conferences should review all of the diagnostic material on those selected cases and compare their own diagnostic impression and the consensus reached at the conference with the diagnosis as stated in the original report. 2. Pathologists who review post-sign out cases should review all of the pertinent diagnostic material and compare their own diagnostic impression with the diagnosis as stated in the original report. 3. The review and results of the review will be entered into the QA section of the CoPath system using the following: TUMOR BOARD CASE REVIEW- Use for cases reviewed for tumor board. TB1 Agreement between the reviewer and the original report. TB2 Minor differences in terminology not deemed to be clinically significant. TB3 Disagreement with some, but not significant, consequences for patient care. TB4 Major disagreement with potential serious impact on patient care. PREVIOUS PATHOLOGY REVIEW- Use for previous cases reviewed in conjunction with a current case, including previous cytologies. Page 5 of 10

PPR1 Agreement between the reviewer and the original report. PPR2 Minor differences in terminology not deemed to be clinically significant. PPR3 Disagreement with some, but not significant, consequences for patient care. PPR4 Major disagreement with potential serious impact on patient care. FOLLOW-UP CASE REVIEW- Use for cases reviewed at request of clinician. Add comment describing the request and actions taken. Add addendum or amendment if needed. FU1 Agreement between the reviewer and the original report. FU2 Minor differences in terminology not deemed to be clinically significant. FU3 Disagreement with some, but not significant, consequences for patient care. FU4 Major disagreement with potential serious impact on patient care. 4. In any case in which a discrepancy exists, the case should be discussed with the pathologist who signed out the original pathology report. 5. If deemed necessary, the pathologist who signed out the original report will generate an addendum report. 6. All category 4 cases will trigger an immediate Comprehensive Case Review. PATHOLOGY CASE DIRECTED AND RANDOM REVIEWS PURPOSE: To ensure quality reporting of Surgical Pathology cases with regards to diagnostic accuracy and report content, a selection of cases will be reviewed retrospectively. The goal is to achieve a 5% overall case review based on the total number of cases from the previous year. These reviews can be either random cases or directed toward a specific procedure or organ system. Random Reviews 1. A random sample of completed Surgical Pathology cases will be selected for review and the slides and reports are gathered together by support staff. 2. The cases are assigned and evenly distributed among the full-time pathologists for review on a rotational basis. 3. The case is initially evaluated for diagnostic concurrence. Concurrence should be based on the substance of the diagnosis allowing for stylistic variability. The following QA system is used to rank the level of concurrence and is entered into the QA section of the CoPath system: SPR1 Agreement between the reviewer and the original report. SPR2 Minor differences in terminology or minor report deficiencies not deemed to be clinically significant. SPR3 Diagnostic disagreement or reporting deficiencies with some, but not significant, consequences for patient care. SPR4 Major diagnostic disagreement or reporting error with potential serious impact on patient care. 4. The reports are further evaluated for content and completeness including the following criteria: a. Specimen source is consistent throughout the report b. Report is free of typographical or grammatical errors c. Overall layout of report is acceptable d. All specimens submitted have a diagnostic interpretation (gross or microscopic) e. Tumor grading as appropriate f. Tumor staging as appropriate g. Nodal status concurrence as appropriate h. Margin status as appropriate i. Complete template information as appropriate 5. The review is entered into the QA section of the CoPath system using the following system: RQR1 No report problems identified. RQR2 Report contains minor editing errors not requiring amendment. RQR3 Report contains editing errors requiring amendment but NOT resulting in a change in secondary diagnostic characteristics (e.g. - specimen source or laterality clarification) RQR4 Report contains editing errors requiring amendment resulting in change in secondary diagnostic characteristics (e.g. change in stage, grade, nodal status or margin status) Page 6 of 10

6. Any comments can be made in the comment section of the QA review screen. 7. The original pathologist will perform any corrections and amendments as needed. 8. All SPR 4 cases will trigger an immediate Comprehensive Case Review. Directed Case Reviews 1. A specific category of cases may be selected for review at the Quarterly PPA meeting. 2. Ten representative cases matching the designated category will be selected either randomly or sequentially and the slides and reports are gathered together by the support staff. 3. The cases are assigned and evenly distributed among the full-time pathologists for review on a rotational basis. 4. The case is initially evaluated for diagnostic concurrence, content and completeness using the process described for Random Reviews. 5. The original pathologist will perform any corrections and amendments as needed. 6. All SPR 4 cases will trigger an immediate Comprehensive Case Review. INTRAOPERATIVE CONSULTATION DIAGNOSIS ACCURACY Intraoperative consultation reporting can have direct effects on patient care. It is important to monitor the adequacy in the performance of intraoperative consultations in terms of diagnostic accuracy and reporting turnaround time 1. An intraoperative consultation includes: a. Frozen section examination of surgical specimen b. Cytological examination or touch preparation of a surgical specimen c. The gross examination of a specimen without a frozen section examination d. A pathologist going into the operating room, at the request of the operating surgeon, to view a specimen in situ or an excised specimen for an opinion and/or orientation 2. A frozen section examination of tissue may be requested for one of the following reasons: a. Establish a diagnosis that may alter the planned operative procedure b. Determine that sufficient or appropriate tissue has been sampled in order to make a diagnosis c. Confirm the adequacy of resection margins d. Obtain additional unfixed tissue for special studies (i.e., culture, electron microscopy, biochemical analysis, immunophenotyping, flow cytometric studies) e. Facilitate patient or family communication f. Promote research or cancer protocol programs 3. Frozen section is the procedure most likely to result in alteration of the planned surgical intervention and is therefore chosen for retrospective review. 4. An intraoperative consultation diagnosis should be rendered directly to the surgeon within 20 minutes of arrival into the department relaying the following information: a. Pathologists name b. Patients name c. Specimen unique identifier (e.g., specimen number) d. Sample used for evaluation (e.g., deep margin) e. Intraoperative consultation diagnosis 1. Each case with a frozen section diagnosis rendered is reviewed at the time of final case review by the pathologist assigned to the case. 2. The reviewing pathologist compares the frozen section diagnosis against the permanent section findings and assigns a discrepancy category according to the parameters delineated below. 3. The reviewing pathologist enters the appropriate intraoperative consultation review code into the QA section of the CoPath system using the category designations at the time of sign out. 4. Discrepancies will be studied according to their effect upon patient care and will be classified using the following: FS1 Agreement between frozen section diagnosis and permanent findings. FS2 Permanent section findings differ from frozen section diagnosis but findings are not present on review of frozen sections. FS3 Minor disagreement with no effect on patient care. FS4 Disagreement with some, but not significant, consequences for patient care. Page 7 of 10

FS5 Major disagreement with potential serious impact on patient care. 5. All FS 5 cases will trigger a Comprehensive Case Review. 6. Frozen Section diagnosis turnaround times will be monitored on an ongoing basis in the following way: a. Pathologist documents on the requisition form the time the frozen section is called to the operating room. b. Support staff enters the time of tissue receipt into the department (per time stamp), the time the frozen section was called (per documentation on the requisition) and the pathologist performing the frozen section. c. The goal of the department is that at least 90% of frozen sections are rendered to the surgeon within 20 minutes of receipt in the department or frozen section room. This 20-minute turnaround time is intended to apply to the typical single frozen section. In cases where there are multiple sequential frozen sections required on a single specimen (e.g., multiple, margins) or if multiple specimens are received on a single case, or in cases where additional studies are required, longer turnaround times may be expected and are not tracked. PATHOLOGY CASE TURNAROUND TIME PPA is committed to providing the clients it serves with accurate diagnoses in a timely fashion. The overall turnaround time of a specimen is a function of many separate processes. Turnaround times (TAT) can be affected by a variety of processes including: 1. Specimen pick-up and delivery to the Pathology Department by the Courier Service 2. Specimen delivery to the Pathology Department by the Surgical Service 3. Accessioning efficiency 4. Gross examination, description and specimen cutting efficiency 5. Histology processing and microtomy 6. Pathologist slide review, dictation and case sign-out efficiency 7. Transcription efficiency The overall TAT goals are based upon recommendations by accrediting bodies including the College of American Pathologists and the Joint Commission on Accreditation of Hospital Organizations. The focus of this review process is on the component contributed by the pathologists. The starting point will be the time entered by the pathology support staff at the time the slides are delivered from the histology or cytology departments. The end point will be the time recorded by CoPath at case sign out. The TAT standards/goals we have adopted include: 1. Routine Surgical Pathology cases: 90% of cases signed out within one (1) working day (Routine cases are cases which generally require simple microscopic examination without special staining, consultation, etc.) 2. Non-GYN cytology cases: a. 90% of cases signed out within one (1) working day b. 100% of cases signed out within two (2) working days 3. GYN cytology cases: 90% of pathologist reviewed cases signed out within one (1) working day 4. Autopsy Pathology cases: a. Preliminary Anatomic Diagnosis (PAD) provided within two (2) working days from performance of the autopsy on all cases b. Final Anatomic Diagnosis (FAD) provided within 60 days on all cases 1. Turnaround time data will be collected via CoPath by the Quality and Compliance officer and tabulated. 2. An individualized report will be given to each pathologist quarterly to review. 3. A quarterly report demonstrating the TAT for the group as a whole will be presented at the quarterly Pathology Department meeting for review and discussion. PATIENT SAFETY There are certain instances where a pathologic/cytologic finding can have significant clinical impact on a patient if not communicated immediately to the patient s provider. The Pathologists of PPA have developed a mechanism of reporting Page 8 of 10

such findings. In line with JCAHO, CAP, and NPSG guidelines, these patient safety initiatives are termed Critical Value Reporting Criteria for Anatomic Pathology. Critical Value Reporting Criteria for Anatomic Pathology: 1. Unexpected findings with immediate clinical impact as determined by the pathologist. Example: No fallopian tube or vas deferens in a sterilization procedure. 2. A finding that may indicate an imminent danger to the patient, as determined by the pathologist. Example: Different tissue type than that supposedly biopsied i.e. kidney in a liver biopsy. 3. Any finding which the reviewing pathologist, in his/her judgment, requires discussion with the clinician, such as, but not limited to, an unexpected diagnosis. 1. Contact the clinical provider of record immediately and relay the findings. 2. Document in the CoPath system that the results were communicated by dictating into the Physician Notification" section of the "final diagnosis" entry/edit screen section: * Dr. XYZ was notified of the results on (date), at (time). Note: This area is for tracking purposes only and will not be displayed in the body of the report. 3. You should consider also dictating a phrase in the comment section of the report if necessary. CALL COVERAGE and COMMUNICATION 1. The pathologists of PPA have a commitment to provide pathology services to the patients and hospitals within our scope of care twenty-four (24) hours a day, seven (7) days a week and three hundred and sixty five (365) days per year. This will include prompt on-call coverage by the pathologists. The pathologists of PPA agree to meet the requirements of the hospitals we cover in order to insure excellent patient care and responsiveness to the surgical and other staff needs. To this end, the pathologists of PPA institute a transit time of no more than twenty (20) minutes for frozen sections or specimen evaluation at all times while on-call. Pathologists will be available by pager or telephone at all times and will respond to pages within 5 minutes. All hospital operators and surgery departments will have updated call schedules provided to them promptly. (Note: The transit time is for Salem Hospital as the vast majority of after hour services are required at this facility. An estimated time of arrival should be clearly communicated to the outlying hospital in the event of an intraoperative consult is required at one of those facilities). 2. A National Patient Safety Goal is related to Physician-to-Physician Handoff Communication. The purpose of this goal is to ensure accurate communication of information that may be needed to ensure quality and safety of patient care. Whenever one pathologist follows up on a case of another pathologist, or there is information related to an anatomic pathology or clinical pathology situation that other pathologists need to be aware of to provide good patient care, there needs to be face-to-face or uninterrupted telephone conversation between pathologists. During this conversation, up-to-date information will be relayed to the pathologist(s) of concern, and an opportunity to discuss and ask questions will be available. Equipment/Supplies (If Applicable): Form Name & Number or Attachment Name (If Applicable): pathologist01 Author Position: Quality officer and Medical director Page 9 of 10

Review/Revision Authority (Position Not Individual Name): Medical Director, Quality Officer Expert Consultant Position/s (Not Individual Name/s): References (Required for Clinical Documents): 1. CAP COMMISSION ON LABORATORY ACCREDITATION, 2004 Anatomic Pathology Checklist. 2. QUALITY IMPROVEMENT MANUAL IN ANATOMIC PATHOLOGY, College of American Pathologists, 1993. 3. Ackerman s Surgical Pathology, Eighth Edition. Mosby-Year Book Inc. 1996, Appendix F. 4. Association of Directors of Anatomic and Surgical Pathology, Recommendations on Quality Control and Quality Assurance in Anatomic Pathology. Am J Surg Path, 15(10): 1007-1009, 1991. 5. Rickert RR. Quality Assurance Goals in Surgical Pathology. Arch Pathol Lab Med. 1990;114:1157-1162. 6. Tomaszewski JE, Baer HD, Connally JA. Consensus Conference on Second Opinions in Diagnostic Anatomic Pathology. AJCP.2000; 114:329-335. 7. Novis DA, Zarbo RJ, Saladino AJ. Interinstitutional Comparison of Surgical Biopsy Diagnosis Turnaround Time. Arch Pathol Lab Med. 1998;122:951-956. 8. Gephardt GN, Zarbo RJ. Interinstitutional comparison of Frozen Section Consultations. Arch Pathol Lab Med. 1996;120:804-809. 9. Novis DA, Zarbo RJ. Interinstitutional Comparison of Frozen Section Turnaround Time. Arch Pathol Lab Med. 1997;121:559-567. 10. Zarbo RJ, Gephardt GN, Howanitz PJ. Intralaboratory Timeliness of Surgical Pathology Reports. Arch Pathol Lab Med. 1996;120:234-244. 11. Salem Hospital Credentials Procedure Manual. Effective January 1, 2005. 12. Joint Commission International Center for Patient Safety Goals. 2006 Joint Commission National Patient Safety Goals. 13. Joint commission Standards for Laboratories (CAMLAB, July, 2010 revisions) 14. CMS Proficiency Testing requirements. 15. What is quality in surgical pathology? J Clin Pathol 2006 59: 669-672 R E Nakhleh Is there a Regulatory Requirement? Yes If yes, insert requirement information here: No Review History (No Changes): Revision History (Note changes in area under header): Computer Search Words: Policy, Procedure or Protocol Cross Reference Information: Page 10 of 10