Quality Assurance

The Joint Commission of Accreditation of Health Care Organizations (JCAHO) and the College of American Pathologists (CAP) use the term quality assurance in a broader sense than the name quality control ; the former refers to a professional activity of the supervising pathologists, whereas the latter refers to the specific mechanisms by which the concepts of quality assurance (QA) are put into effect (19). A review of the inspection checklists reflects these concepts. The lists cover questions related to the running and maintenance of the morgue and the autopsy and histopathology laboratories; they also refer to safety issues, record keeping, the interactions between staff and technicians, the quality of autopsy documents, and the timeliness of reporting. In short, the questions in the checklists that must be answered and evaluated before an autopsy service is accredited reflect the expectations of excellence as described in the CAP manual (20).

Accreditation also requires that each service has an intrade-partmental quality assurance program. Educational activities such as organ reviews and clinicopathologic conferences are part of such a program but also quality control of the autopsy itself (21-26). This typically consists of a review of all autopsy documents and slides pertaining to a specified, randomly selected number of cases—for example, 5% of all autopsies. The review generally is the responsibility of another staff pathologists. A review form is filled out and filed. The reviewing pathologist states as a minimum whether he or she agrees with the diagnoses and the written communications such as letters to the clinician and next of kin, that were based on these diagnoses. Also evaluated are the histologic findings, the quality and number of slides, and the adequacy of microbiologic and other laboratory studies, and photographs. Finally, the reviewer evaluates whether protocol descriptions and clinical abstracts are complete and clear and whether documentation and reporting had been completed within the agreed-upon time limits (27). Subspecialties such as neuropathology (28) and pediatric pathology (29) are developing their own QA programs.

Preliminary studies suggest that in general, a good agreement exists between pathologists in the diagnosis of the main diseases but that the agreement was less in the establishment of the immediate cause of death and in the diagnosis of minor diseases (30). As one would expect, discrepancies between ante-mortem and postmortem diagnoses also tended to increase with the age of the patient (31).

In addition to these intradepartmental QA activities, the autopsy findings also become an important part of extradepart-mental quality assurance programs (21,22,32), primarily in the departments of internal medicine and surgery. Because of sample-selection bias, this method must be applied with caution (32). In institutions that use autopsies in this manner, the final autopsy diagnosis and a cover letter are sent to the clinicians who took care of the patient but also to the colleague who acts as clinical QA officer; that physician also receives a form that specifically addresses clinical QA issues, for example, if a major disease or condition had not been recognized. Timeliness of reporting is exceedingly important in this context (27).

Review of autopsy services for accreditation purposes concentrates primarily on activities within the service. The reporting to clinical departments for external QA programs is also evaluated but the usage of the information by these departments is evaluated by their own accreditation procedures.

It should be noted that quality control needs to be applied not only to the original autopsy documents but also to the codes (generally ICD and SNOMED codes) that are generated from these documents.

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Blood Pressure Health

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