The role of peer review in internal quality assurance in cytopathology

Benign proliferative breast diseases among female patients at a sub-Saharan Africa tertiary hospital: a cross sectional study

Background

Non-cancerous diseases of the breast have assumed increasing importance because of the public awareness of breast cancer. These benign diseases are a recognized important risk factor for later breast cancer which can develop in either breast. The risk estimate of these benign breast diseases has not been well established in sub Saharan Africa. Women with benign proliferative or atypical breast lesions have a two- fold risk of developing breast cancer in western populations. The purpose of this study therefore was to determine the prevalence of proliferative disease ( BPBD) with and without atypia among Ugandan Black women.

Methods

A cross-sectional descriptive study conducted at Mulago Hospital Breast Clinic between January 2012 and June 2012; 208 women aged 12 years and above with palpable breast lumps were screened. Fine needle aspiration biopsies were taken for cytological examination.

Results

Of the 208 women with benign breast lumps screened, 195 were recruited in the study. The prevalence of BPBD was 18% (35/195). BPBD with atypia was 5.6% (11/195). The mean age and body mass index (BMI) were 28.4 years and 23.26 kg/m² respectively. The commonest lesions were fibroadenomas for 57%, (111/195), and fibrocystic change were 21% (40/195). Most BPBD with atypia lesions were in the fibrocystic category.

Conclusions

Benign proliferative breast diseases are common, found mostly among premenopausal women. A significant proportion of BPBD had atypical proliferation. An accurate breast cancer risk estimate study for BPBD is recommended.

[Peer review procedures in pathology - more than ten years of experience in the free state of Saxony]

The positive experiences regarding peer review practice go back to the 1990s and can be traced in the position paper of the German Medical Association concerning quality assurance in the field of pathology. This evolved into the initiative of pathologists in Saxony to implement the peer review practice within the remit of their State Medical Association. Since the 14(th) of May 1999 various institutes as well as medical group practices in pathology and cytology have joined forces to undertake voluntary inter-institutional quality control measures. The aim was to improve the process and especially the outcome quality by reviewing each other's quality (analysing samples) on the basis of defined criteria. A positive review outcome report, which will have to be unanimously agreed upon by all participants, will lead to a positive recommendation for a certificate issued by the Medical Association of Saxony. Between 1999 and 2011 a total of 56 peer review proceedings took place. The potentials for improvement concern the problem of "kitchen pathology" still being used in the context of macroscopic description, the quality of microscopic description including the use of correct nomenclature, the quality of tumour classification and immune histological investigations. Statements concerning the advantage of the peer review method in particular refer to the integration of resident pathologists. Due to the long period of implementation of the peer review system und the small number of proceedings, it is not possible to come to a clear conclusion about the improvement or deterioration of quality. During a period of more than 10 years three peer review proceedings were not successful. In this situation, it is appropriate to ask the question of how restrictive peer reviews should be. The three most important aspects for the pathologists in Saxony are: self-determination, learning from each other, and a commitment to quality improvement. So this method set an example of how a quality management method can persist for more than 10 years through voluntary engagement. And the initiative of pathologists in Saxony has given an important impetus to the development of other peer review systems in various health care organisations or disciplines in Germany.

Mapping turnaround times (TAT) to a generic timeline: a systematic review of TAT definitions in clinical domains

BACKGROUND

Assessing turnaround times can help to analyse workflows in hospital information systems. This paper presents a systematic review of literature concerning different turnaround time definitions. Our objectives were to collect relevant literature with respect to this kind of process times in hospitals and their respective domains. We then analysed the existing definitions and summarised them in an appropriate format.

METHODS

Our search strategy was based on Pubmed queries and manual reviews of the bibliographies of retrieved articles. Studies were included if precise definitions of turnaround times were available. A generic timeline was designed through a consensus process to provide an overview of these definitions.

RESULTS

More than 1000 articles were analysed and resulted in 122 papers. Of those, 162 turnaround time definitions in different clinical domains were identified. Starting and end points vary between these domains. To illustrate those turnaround time definitions, a generic timeline was constructed using preferred terms derived from the identified definitions. The consensus process resulted in the following 15 terms: admission, order, biopsy/examination, receipt of specimen in laboratory, procedure completion, interpretation, dictation, transcription, verification, report available, delivery, physician views report, treatment, discharge and discharge letter sent. Based on this analysis, several standard terms for turnaround time definitions are proposed.

CONCLUSION

Using turnaround times to benchmark clinical workflows is still difficult, because even within the same clinical domain many different definitions exist. Mapping of turnaround time definitions to a generic timeline is feasible.

Measuring against clinical standards

Systematic improvement of health services requires the objective measurement of people, practices and organisations against valid and explicit standards in order to identify and implement appropriate change. Effective quality systems must embrace a wide range of definitions of quality, and a similar variety of approaches to defining, measuring and improving. Clinical performance may be examined from three professional viewpoints--clinical competence: assessment of individual practitioners against explicit criteria to recognise achievement and to promote continuing development. Traditional mechanisms of training, registration and accreditation enable clinicians to reach career grades but responsibility for subsequent support is often unclear between employers, professions and registering bodies. Clinical practice: assessment of actual clinical process and outcomes against research-based "best practice" to identify and reduce variation. Peer review, clinical audit and confidential enquiries are examples of this approach, which may involve single or multiple professional groups and their interface with management. Service accreditation: systems to assess health care organisations against published standards in order to encourage best management practice. These are usually run on a regional or national basis and, though sensitive to expectations of patients, managers, clinicians, paying agencies and government, they are usually managed by an impartial but authoritative organisation.