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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 3  |  Page : 325-327
In-house daily consensus conference: An important quality control/quality assurance activity - Experience at a major referral center


Department of Pathology and Microbiology, Aga Khan University Hospital, Karachi, Pakistan

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Date of Web Publication12-Aug-2009
 

   Abstract 

Background: For every practicing histopathologist, improvement of diagnostic accuracy is an important objective. Personal consults are an important component of quality control (QC)/quality assurance (QA) in our Section of Histopathology. In addition, the College of American Pathologists recommends a daily in-house consensus conference, which is a prospective system by which all difficult and problematic cases are reviewed and discussed and signed out by consensus. Design: In-house consensus conference is held daily using a multi-headed microscope. This collegial session is run by the seniormost consultant in the section and is attended by all histopathology consultants and residents. The consultants and residents present cases of their choice for discussion. The cases may be selected due to diagnostic difficulty, unusual nature of a case, management purposes such as performance of additional biopsies, special studies, etc., or request on the part of clinician or patient. Cases may be shown once or, in case of lack of consensus or difficulty in diagnosis, more than once after additional work-up suggested by the conference. Results: In a 4-month period, 774 (4.1%) cases of a total of over 14,000 well-mixed surgical cases were brought to the in-house daily consultation conference. Four hundred ninety-three cases (63.7%) were conclusively decided the first time while 198 cases (25.5%) were decided by consensus after being shown twice. In 83 cases (10.7%), a definite diagnosis could not be given. The cases on which a definite diagnosis was not possible represents 0.59% of all cases received in the department during the study period. The most common cases were shown from the gastrointestinal tract (115 cases or 14.8%), lymph nodes (110 cases or 14.2%) and soft tissue (82 cases or 10.6%). In most cases in which a definite diagnosis could not be given, the main reason was scanty material or crushed nature of the tissue. Conclusion: The in-house daily consensus conference is an extremely useful QC/QA exercise, which is very important in reaching an accurate diagnosis in difficult and challenging cases and minimizing diagnostic errors.

Keywords: Daily in-house consensus conference, departmental consultation conference, quality control/quality assurance

How to cite this article:
Khurshid A, Ahmad Z, Qureshi A. In-house daily consensus conference: An important quality control/quality assurance activity - Experience at a major referral center. Indian J Pathol Microbiol 2009;52:325-7

How to cite this URL:
Khurshid A, Ahmad Z, Qureshi A. In-house daily consensus conference: An important quality control/quality assurance activity - Experience at a major referral center. Indian J Pathol Microbiol [serial online] 2009 [cited 2019 Oct 16];52:325-7. Available from: http://www.ijpmonline.org/text.asp?2009/52/3/325/54985



   Introduction Top


For every practicing surgical pathologist, improvement of diagnostic accuracy is an important objective. Several retrospective and prospective methods are available that are important in the attainment of this objective. Organizations such as the College of American Pathologists (CAP) have published quality assurance (QA)/quality control (QC) programs to ensure not just diagnostic accuracy but also completeness and timeliness of all surgical pathology reports. [1] CAP recommends a daily in-house consensus conference, which is a prospective system by which all difficult and problematic cases are reviewed and discussed and signed out by consensus. In our section, personal consults among colleagues are an important component of QA/QC activities. A Departmental Consultation Conference (DCC.) is held daily (on all working days) on a multi-headed microscope. Difficult and unusual cases are shown by consultants and residents and diagnoses are given by consensus. This activity has been going on regularly in our section now for over 7 years and has proved to be an extremely useful and rewarding exercise in our neverending quest and goal of attaining improved diagnostic accuracy. This collegial session is run by the seniormost consultant in the section and is attended by all surgical pathology consultants and residents. All records of DCC since its inception are available in the Department for quick reference. In future, we intend to computerize all these data.


   Materials and Methods Top


The daily in-house consensus meeting called DCC in our section is held daily on all working days. It is presided over by the seniormost consultant in the section and is attended by all surgical pathology consultants and residents, who present for discussion cases of their choice. The cases are selected due to diagnostic difficulty, unusual nature, for management purposes such as performance of additional biopsies, special studies etc. or request on the part of clinician or patient. The criteria for showing cases have deliberately not been kept tight. Hence, consultants are encouraged to show any case that they find difficult individually or after having shown it to one or more colleagues. They may also show cases that they feel should go out with a consensus statement. Cases may be shown once or, in case of lack of consensus or difficulty in diagnosis, more than once after additional work-up suggested by the conference. The consensus may be reached on the basis of Hand E alone in a few cases, but in the majority of the cases, final diagnosis is reached with the help of additional work-up (leves/recuts, additional sections, special stains, immunohistochemistry, etc.) either performed by the primary consultant or any additional work- up suggested by the conference. Once cases have been shown, a resident/faculty who is assigned for the purpose enters the following information in a special book kept as official record of DCC: Pathology number, Name of presenter, Consensus diagnosis reached, Any further workup that has been recommended.

Once a consensus is reached, the case is signed out by the primary consultant and a comment identifying the presentation of these cases in the DCC is incorporated in the final report.


   Results Top


Cases shown in the DCC over a 4-month period were included in the current study.

In a 4-month period, 774 cases(4.1%) of a total of over 14,000 well represented surgical cases were brought to the in-house daily consultation conference. A definite, conclusive diagnosis was possible in 691 (89.3%) cases. Four hundred ninety-three cases (63.7%) were conclusively decided the first time while 198 cases (25.5%) were decided by consensus after being shown twice. In 83 cases (10.7%), a definite diagnosis could not be given. These 83 cases on which a definite diagnosis could not be given comprised 0.59% of the total number of cases received in the department during the study period, i.e. 14,000. Of the 691 cases on which a definite, conclusive diagnosis was given, 425 cases (61.5%) were malignant neoplasms, 54 (7.8%) were benign neoplasms and 212 (30.7%) were non-neoplastic. The most common organ systems/tissues from which cases were brought to the meeting are shown in [Table 1]. The breakup of cases decided the first or second time as well as undecided cases is shown in [Table 2].


   Discussion Top


Organizations such as the CAP have published QA/QC manuals to ensure not just diagnostic accuracy but also completeness and timeliness of all surgical pathology reports. [1] Similarly, the Association of Directors of Anatomical and Surgical Pathology (ADASP) has also published position papers, editorials and recommendations about various aspects of the practice of surgical pathology. In this connection, an ad hoc committee of ADASP in 1991 prepared a document on Quality Control and Quality Assurance in surgical pathology in which a consensus conference was recommended for a review of selected cases by the consultants as a group. [2] These recommendations were updated in new documents published in 2006. [3],[4] A description of the QC/QA program set up in the Department of Pathology at Yale University appears in a major Surgical Pathology text book, which also recommended a prospective daily in-house collegial session for discussion of difficult and challenging cases on a multi-headed microscope. [5] Several surgical pathology residency and fellowship programs in the United States project a daily intra-DCC, where consultants share their interesting cases and get diagnostic input from colleagues, as a major strength of their residency/fellowship program.

In our section, the daily in-house consensus conference called DCC has been held with great success for over 7 years. On an average, eight to 10 cases are shown in the 1 h designated daily on all working days for this purpose. In the 4-month period under study, 4.1% of a total of 14,000 cases were shown in DCC. No definite diagnosis could be given in 10.7%. In most of these cases, the main reason for failure to give a definite diagnosis was scanty material or crushed nature of the tissue or non-representative tissue, in which case rebiopsy was strongly recommended in the final report with clear comments about the reasons why a definite diagnosis was not possible. Some cases were poorly differentiated or undifferentiated neoplasms, the exact characterization of which was not possible even after exhaustive immunohistochemical work-up. In such cases also, morphological differential diagnosis is given in the final report to guide the clinician. There were squamoproliferative lesions where tissue was too superficial and no deeper tissue was present to reliably assess invasion. Such cases were signed out as inconclusive and repeat biopsy was advised. As shown in the results, the highest number of cases was reported from the gastrointestinal tract (GIT). The main reason is the sheer number of cases from the GIT that we see. However, as shown in [Table 2], more than 70% of the cases from the GIT were solved the first time they were shown in the DCC. Cases from lymph nodes and soft tissue were also shown commonly but, compared with the GI, cases a significant percentage of these cases had to be shown in the DCC more than once before they could be resolved. As shown in [Table 2], most cases (63.7%) were resolved the first time they were shown in the DCC. Each faculty member has developed specific interests, and informal personal consults among faculty are very common in our section. Certain consultants have very specialized interests, such as muscle pathology, neuropathology, non-neoplastic renal pathology, etc. These consultants are shown many cases as personal consults and that may be the reason why so few renal or muscle cases are shown in DCC. In addition, lymphomas, breast, bone, soft tissue cases, etc. are so common that many of them are shown as personal consults to faculty with interests in these specific fields.

However, the most difficult and challenging cases are brought to the DCC and it provides a great setting for a stimulating discussion, reading of latest texts (and papers), brain storming and is an invaluable learning experience, especially for residents, with tremendous educational merits.

Sharabi, [6] in a yet unpublished study, showed that 243 cases of 6847 surgical pathology cases (3.5%) were brought to the in- house daily consensus conference, a figure slightly lower than our 5.5%. There is sparse data on the in-house daily consensus conferences and our data can set a reference point for predicting send out volume for cases if a daily conference is conducted. Our findings may also encourage pathology departments in large institutions, especially in our part of the world, to conduct similar in-house daily consensus conferences, which may serve as excellent QA/QC exercises towards the goal of attaining improved diagnostic accuracy in surgical pathology practice.

 
   References Top

1.Nakhleh RE, Fitzgibboun PL. Quality improvement manual in anatomic pathology. 2 nd ed. Northfield, IL: College of American Pathologists; 2002.  Back to cited text no. 1    
2.Association of Directors of Anatomic and Surgical Pathology. Recommendations on quality control and quality assurance in anatomic pathology. Am J Surg Pathol 1991;15:1007-9.  Back to cited text no. 2    
3.Nakhleh R, Coffin C, Cooper K. Association of Directors of Anatomic and Surgical Pathology. Recommendations for quality assurance and improvement in surgical and autopsy pathology. Hum Pathol 2006;37:985-8.  Back to cited text no. 3    
4.Association of Directors of Anatomic and Surgical Pathology. Recommendations for quality assurance and improvement in surgical and autopsy pathology. Am J Surg Pathol 2006;30:1469-71.  Back to cited text no. 4    
5.Appendix B. Quality control and quality assurance in surgical pathology. Intradepartmental consultation (IDC). In: Rosai J, editor. Rosai and Ackerman's Surgical Pathology. 9th ed. St Louis, Missouri: Mosby, Elsevier Inc; 2004. p. 2793-9.  Back to cited text no. 5    
6.Sharabi G. Statistical analysis of Surgical Pathology In house peer consultation in a large university hospital setting. Abstract presented at the United States and Canadian Academy of Pathology. Annual Meeting, San Diego, California, March 24-30, 2007.  Back to cited text no. 6    

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Correspondence Address:
Zubair Ahmad
Department of Pathology and Microbiology, Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi - 748 00
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.54985

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