Download Royal College of Pathologists of Australasia 10 February 2012

10 February 2012
Mr Bill Lawrence AM
Acting CEO
Australian Commission on Safety and Quality in Health Care
GPO Box 5480
Sydney NSW 2001
Email: [email protected]
Dear Mr Lawrence
RE: Australian Safety and Quality Goals for Health Care: Consultation paper
The Royal College of Pathologists of Australasia (the College) welcomes the opportunity to
comment on this important document. Overall, the College is supportive of the contents of
the document however would like to note that pathology is vital to the quality of healthcare
and is related to almost all goals of diagnosis and monitoring and that it is disappointing that
pathology is not mentioned more frequently in the document. The College encourages the
Commission to ensure that the overarching impact across the board on all of the Goals of
pathology and the pathologist workforce is taken into account when developing the Goals
further.
Some examples of this are given below, with reference to the three Draft Goals and their
priority areas:
Goal 1. Safety of care: That people receive their health care without experiencing
harm.
Initial priorities are to:
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reduce harm from adverse medicines events and improve quality use of
medicines
College comment: Monitoring of adverse harm from medicines includes pathology
testing ranging from liver and muscle toxicity of statins, to renal toxicity of antibiotics,
to bone marrow suppression and anaemia and hormonal disturbances caused by
medications such as anticonvulsants and anti-arrythmics.
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reduce harm from healthcare associated infections through effective infection
control and antimicrobial stewardship.
College comment: The identification of the agents of infection is performed by
pathology and hospital infection control depends on the results on pathology analysis
and strategies and governance are often dependent on advice from microbiology
specialist pathologists. The inappropriate prescribing of antibiotics is an area of major
concern and responsibility in pathology laboratories where the testing for drug
sensitivity and resistance is reported and monitored.
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Goal 2. Appropriateness of care: That people receive appropriate, evidence-based
care.
Initial priorities are for:
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people living with type 2 diabetes
College comment: Type 2 diabetes is diagnosed by pathology (blood glucose) and
monitored by pathology (‘HbA1c < 7%’) and the management of complications are
also dependent on pathology tests (eg urine microalbumin, cholesterol management
goals). Pathologists are key specialists in determining the appropriate timing and test
combinations for patients with this chronic condition.
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people with acute coronary syndrome or stroke.
College comment: The modern definition of acute coronary syndrome is primarily
dependent on the new Troponin blood test which has revolutionised the assessment
of cardiac damage and risk. The diagnosis and its risk are heavily dependent on the
integrity of pathology testing. While this seems to be neglected in the discussion of
this issue in this consultation document, it may be because it is taken for granted,
which is why the integrity of testing becomes vital. Any cardiologist would be aware of
the importance of sample integrity to the management of this condition.
Goal 3. Partnering with patients and consumers: That there are effective partnerships
between patients, consumers and healthcare providers and organisations at
all levels of healthcare provision, planning and evaluation.
College comment: The interaction of the patient with pathology collectors and the
communications in pathology reports are some of the most common patient
interactions in modern medicine. Pathology laboratories partner with doctors and
patients in providing feedback on their diagnosis and ongoing management. The
integrity of that information is a critical element that is immediately visible to patients.
The College responses to specific consultation questions are outlined below.
1.
How do you think national safety and quality Goals could add value to your
existing efforts to improve the safety and quality of care?
Pathology and pathologists are more likely to be able to assist others in achieving these
Goals. Laboratory medicine itself is already closely monitored by a highly regulated and
effective accreditation system involving NPAAC, RCPA/NATA, RCPA/QAP etc. It is
through this rigorous process that the College is able to identify the priority areas
described below.
2.
Do you agree with the topics that have been included as Goals and priority?
In the main, the Goals are very relevant for patient care and safety, however the College
has identified a number of other, potential priority areas:
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one critical topic which is missing from Goal 1, is the correct identification of the
patient. If a patient is not correctly identified, the ramifications can be severe and
affect many areas of care from medication, pathology test results and treatment for
the patient. In extreme cases incorrect identification of the patient can lead to
death. The College proposes a specific priority area under Goal 1: Safety of
Care related to collection and patient identification errors in pathology. A
detailed response as to how this topic satisfies the criteria used to select the Goals
is outlined below under point 6.
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3.
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variation in pathology reporting (eg different units, test names etc) has the potential
to lead to misinterpretation and clinical error and this is being addressed through
the Pathology Units and Terminology project (PUTS) being funded by the Federal
Quality Use of Pathology Program.
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variability in testing rates for different indications. We do not have a mechanism
nationally to identify such variation, identify the causes, and take actions to improve
the appropriate utilisation of tests. This is currently being addressed through the
Pathology Electronic Decision support project being led by the College with the
RACGP under the National Pathology Agreement.
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Turnaround times for urgent samples (particularly from Emergency Departments).
The ACHS data on Clinical Indicators to Improve the Quality of Healthcare for
Pathology has consistently demonstrated that turnaround times for urgent samples
show wide variation and, in a significant number of instances, poor performance (eg
some facilities achieving targets for <50% of cases vs others achieving targets for
>95% of cases). Significant adverse impacts include prolonged patient length of
stay/overcrowding in Emergency. It would be useful to use the Collected to
Validated and the Received to Validated times for Potassium (marker of chemistry
turnaround times) and Haemoglobin (marker of haematology turnaround times).
This would require only one additional measure to data sets that have been
collected for a number of years. It also affords the opportunity to set reasonable
targets based on the historical ACHS data.
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Build on the previous work through the Commission for bridging the gap between
coroners/forensic pathology and health departments regarding provision of
autopsies and medico-legal clinical case review as well as the advice forensic
pathologists provide to Coroners, the legal profession and health department
consultative councils (surgical, anaesthetic and obstetric/perinatal etc).
What do you think about the specificity of the Goals and priority areas? Are they
too broad or too specific?
The College notes that the Goals appear broad and the priority areas are specific, which
appears to be a reasonable approach.
4.
Do you think there should be specific targets attached to the Goals or priority
areas? If so, what form should a target take?
The College supports the use of targets as they provide organisations with an ability to
measure their performance relative to their peers. In order to achieve this, baseline data
is required and should be utilised to measure improvements. Targets can be in the form
of benchmarks, set at national level or standards that need to be met.
5.
How do you see the Goals applying in different healthcare settings or for different
population groups?
The College has no specific response to this question.
6.
What systems, policies, strategies, programs, processes and initiatives already
exist that could contribute to achievement of the Goals?
In pathology, the Royal College of Pathologists of Australasia (RCPA), Quality
Assurance Programs (RCPA QAP) offer external quality assurance for medical
(pathology) laboratories in Australia and internationally. In 2007, RCPA QAP piloted a
program to measure pathology incidents and their impact on patient safety, with funding
from the Quality Use of Pathology Program (QUPP). The Key Incident Monitoring &
Measurement Systems (KIMMS) program is now an established QAP.
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In regard to the collection of pathology incidents and misidentification in
particular, there are many criteria for a priority area under Goal 1 satisfied.
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the impact on the health system in terms of issues such as the burden of
disease, cost to the system and number of adverse events.
The KIMMS program identifies 100,000 pathology identification incidents per annum
but not all pathology laboratories in the country are monitored because currently the
programme is optional.
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the existence of significant safety and quality problems, such as high levels of
preventable harm and significant gaps between evidence and practice.
Some incidents, such as transfusion sample errors, identified by laboratory quality
systems are considered near miss incidents that could have been fatal. Others (e.g.
haemolysed samples) at one end of the spectrum ‘only’ cause sample recollection
and delays in diagnosis and management but could, at the other end of the spectrum,
lead to misleading diagnoses and management.
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the existence of a body of work that could be built on to make improvements,
with broad agreement about clinical guidelines or other evidence-based
strategies
RCPA QAP has been providing external quality assurance programs to Australasian
Pathology laboratories for over 30 years and is considered one of the most
advanced, profession based quality programs in the world with participants in 40
countries. The KIMMS program has developed over the last 5 years to be the most
advanced non-analytical quality assurance program available anywhere in the world.
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that the potential goal was amenable to national action at multiple levels of the
health system
The program already involves a hundred pathology entities that include statewide
public pathology services and nationwide private pathology services. The program
monitors not only the integrity of pathology episodes handled by pathology staff but
also identifies incidents that occur at high frequencies across the health profile
especially in critical clinical areas such as emergency departments and high
dependency wards where the likelihood of errors seem to be greater.
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the likelihood that improvements would be achieved in a three to five year
timeframe
Participants have reported that risk areas identified in the KIMMS program can be
addressed by both improved technology e.g. electronic patient identification,
computerised pathology requesting and advances in sample integrity procedures in
the laboratory.
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the existence of links to other national priorities
The issue of sample identification has direct links with the National Blood Authorities
concerns regarding life threatening transfusion reactions and the patient identification
issues are directly related to the issues in pharmaceutical safety .These direct links
are recognised in pages 14 and 15 of the document when discussing ways to reduce
pharmaceutical adverse events.
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the potential for the goal to be relevant across disease groups, sectors and
settings of care
There are very few clinical areas that aren’t dependent on pathology tests. Even in
psychiatry where pathology plays little role in diagnosis, drug levels and drug sideeffects are of major clinical importance. Similarly in orthopaedics, imaging may be
more important for diagnosis than pathology, however surgery carries its own clinical
risks and pathology tests are vital in assessing post-operative risk and recovery and,
most certainly, for histological confirmation of soft tissue and bony lesions.
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the existence of measures, or potential to develop measures, that could be
used to monitor progress.
KIMMS has numerous measures that can be extracted from pathology information
systems and software vendors are increasingly aware of the need for this facility in
any new tenders and installations.
The College has no specific comments on the last three questions (below) as these inputs
are more appropriate to health service providers:
7.
What do you think should be the initial priorities for action under the Goals?
8.
How could the different stakeholders within the healthcare system be engaged in
working towards achievement of the Goals?
9.
What barriers exist in achieving the Goals? How could these be overcome?
Once again the College appreciates this opportunity and, as the peak body responsible for
quality and professional issues impacting on pathology and pathologists in Australasia, looks
forward to ongoing input to development and implementation of the Goals.
If you have any queries or concerns, please contact Dr Debra Graves, CEO on 02 8356
5830 or [email protected].
Yours sincerely
Professor T Yee Khong
President
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