Increasing the efficiency of autopsy reporting.
* Context.--When autopsy reports are delayed, clinicians and
families do not receive information in a timely fashion.
Objective.--Using lean principles derived from the Toyota Production System, we set out to streamline our autopsy reporting process.
Design.--In a formal workshop setting, we identified the steps involved in producing an autopsy report, then sought to eliminate, abbreviate, or reschedule them into a more efficient format. We established intermediate deadlines for each case, taking care to make them visible; we initiated a weekly quality assurance review, giving attention to both scientific issues and approaching deadlines.
Results.--By adopting a more standardized approach, eliminating redundancy, and improving the visibility of tasks, we improved the mean completion time of autopsy reports from 53 days (N = 47 cases) to 25 days (N = 47 cases). Previously, 17% of reports were completed by 30 days and 71% by 60 days; in the 15 months following initiation of the program, 72% of reports were completed by 30 days and 100% by 60 days. A follow-up survey of attending physicians revealed continuing appreciation for the autopsy and timely communication, with no perceived diminution in the quality of reports.
Conclusions.--This approach was of great benefit in our laboratory and may assist others in reducing the turnaround time of their autopsy reports. It may also benefit other areas of the laboratory.
Pathologists (Powers and duties)
Medical care (Quality management)
Medical care (Standards)
|Author:||Siebert, Joseph R.|
|Publication:||Name: Archives of Pathology & Laboratory Medicine Publisher: College of American Pathologists Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 College of American Pathologists ISSN: 1543-2165|
|Issue:||Date: Dec, 2009 Source Volume: 133 Source Issue: 12|
|Topic:||Event Code: 353 Product quality; 350 Product standards, safety, & recalls; 200 Management dynamics|
|Organization:||Organization: College of American Pathologists|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Like other health care workers, pathologists must assign priorities
to their daily tasks. It is possible, in doing this, to give less
emphasis to the autopsy--and particularly to completion of the autopsy
report--than to responsibilities that are considered more pressing. The
delay of autopsy reports can, however, be deleterious in a number of
ways. Clinicians may not receive postmortem findings in a timely manner;
families, waiting for results, may experience heightened anxiety;
guidelines mandated by accrediting agencies, such as the College of
American Pathologists (CAP), may not be met. (1) Delays in the process
are also inefficient for the pathologist. Clinical histories, reviewed
at the time of gross examination, may need to be revisited days or weeks
later at sign-out; gross and microscopic findings may also need to be
reviewed more than once. Such processes are wasteful when they need to
be reworked. The Toyota Production System has proved effective in
increasing efficiency in numerous hospital and laboratory settings.
(2-7) Using the lean principles of this system and a standardized
approach for performance improvement, we sought to review our reporting
process and make it more efficient while retaining its quality.
MATERIALS AND METHODS
To maintain and increase the efficiency of its many departments, Seattle Children's Hospital in Seattle, Washington, uses a continuous performance improvement (CPI) team, composed of individuals trained to assist in understanding and streamlining workflow. With the help of the CPI team, we examined our system of autopsy reporting.
We first conducted a baseline audit of reporting (turnaround) times. We then organized a 3-day (8 hours per day) workshop, which included workers from each section of our laboratory, ie, staff pathologists, a pathology fellow, a histology technologist, and an administrative secretary. In the workshop, we identified the tasks, transfers of materials, and queues--those times or locations when workflow stagnates--involved in the autopsy process. We examined each step to see if any could be rescheduled, abbreviated, or eliminated. We then implemented several changes, described below, and conducted a second audit to reexamine the completion times of autopsy reports. Finally, we surveyed attending clinicians to measure the effect of these changes.
An audit of autopsy reports issued in the 15 months before our performance review showed that the completion rate did not meet CAP standards in all instances (Table 1). Provisional anatomic diagnoses were issued within 2 days in only 26% of cases; 17% of reports were completed in 30 days, and 71% in 60 days. Reporting times were highly variable (Figure 1, A and B). Reports were delayed for a variety of reasons (Table 2).
We sought to take several steps to improve this rate. In the workshop, we identified a total of 77 steps involved in our overall autopsy process. Steps included every transfer of material from one worker or area of the laboratory to another. As examples, a resident's delivery of tissue to the histology laboratory or a technologist's return of stained slides would each constitute one step; each transfer of documents between secretary and pathologist was counted as one step. In scrutinizing this list, we were able to reduce the total number of steps by 8%. We also identified queues, those steps where an item awaited the next step in the process. Examples were tissue waiting to be processed, a document waiting to be signed, or a report waiting to be verified. These proved to be major sources of delay, inefficiency, or redundancy. The latter was especially evident when tasks needed to be repeated as work on cases was resumed.
By identifying queues, we could question why they existed, whether they were necessary, or how they might be shortened or eliminated. Several measures were introduced to reduce queues. First, we established a set of intermediate deadlines for each case, corresponding to the various stages in the reporting process and totaling 30 workdays. These deadlines were flexible to accommodate the work schedules of pathologists and trainees and time out of the office. We designed loose-leaf binders for each case. These had an outside flow sheet for tracking deadlines (Figure 2) and interior pockets that made storing materials more systematic (eg, preliminary and final diagnoses, autopsy protocol, photographs, clinical history, other data or reports, references, and notes). We created a wall-mounted status board to display the progress of each case (Figure 3). We initiated a weekly, 1-hour autopsy conference to review cases, with emphasis given to both clinical/scientific aspects of the case and approaching deadlines.
We removed the problem of "finding time for the autopsy" by encumbering time on the attending pathologist's schedule at the time of autopsy for essential steps such as completing provisional diagnoses, examining the brain, reviewing slides, and producing a clinical-pathologic correlation. At the time of each autopsy, we identified the physicians responsible for follow-up with families, so that we could keep them apprised of progress and allow them to plan for their family conferences.
[FIGURE 1 OMITTED]
In maintaining these procedures during the ensuing 15 months, we reduced our reporting time to an average of 25 days (N = 47). In 87% of cases, provisional anatomic diagnoses were issued within 2 days; autopsy reports were completed within 30 days in 72% of cases and 60 days in all cases (Table 1). The variability in reporting times was narrow (Figure 1). Completion time exceeded 30 days by a significant amount in only 2 cases: 1 for nonspecific reasons (38 days) and 1 that required additional metabolic testing at an outside laboratory (58 days).
A survey of attending physicians after the implementation of these changes indicated that the autopsy continued to have high value and application, that the quality of reports did not suffer as a result of reduced reporting time, and that the increased communication was much appreciated (Table 3).
A myriad of studies has demonstrated the value of the autopsy (8-15) and the importance of producing timely autopsy reports. (16-20) Recognizing these facts and the difficulties in reducing reporting times, we took several steps to improve our completion times for provisional anatomic diagnoses and autopsy reports. First, our group acknowledged that improvement was desirable and possible, but would require effort, especially if the quality of our autopsy reports was to be preserved. Demands upon pathologists' time are significant and continual, though presumably variable among institutions. One study (21) has shown, for example, that reporting times tend to be shorter in nonacademic and more rurally located institutions.
The review and restructuring of our reporting process was based on lean principles derived from the Toyota Production System. (2,22,23) These principles have been used with success in diverse branches of the health care system, including the laboratory. (3-7,24-26) They apply to the autopsy reporting process as well (Table 4). We began with a workshop to identify the value-added steps in our process and map a value stream that graphically described these steps. At 3 days, the workshop represented a significant outlay of time. However, we found that the investment benefited us in a number of ways. It provided sufficient time to analyze current systems; it allowed participants from each part of the laboratory to become engaged in the process and achieve consensus regarding change; and, it gave us time to develop priorities and methods for improvement. As a result, we identified steps that added value to our workflow and eliminated those that did not. We reduced the total number of steps in the reporting process by 8%, a relatively small improvement and one that will presumably vary from practice to practice.
[FIGURE 2 OMITTED]
[FIGURE 3 OMITTED]
However, this decrease was not the major benefit. Larger gains in efficiency came from eliminating redundancy and other delays. By adopting a more systematic approach to workups and compressing the time to completion, the clinical history was reviewed only once. We reduced the handling time of each document by making the storage of materials more uniform. Importantly, we increased the visibility of pending tasks. This "visual control" reduced the number and duration of queues and was achieved in several ways. Flow sheets were incorporated into the front covers of autopsy binders and a large, wall-mounted tracking board was located prominently in the office area. The progress in reporting was thus available for scrutiny on a daily basis and at the weekly autopsy conference. With increased visibility of unfinished tasks came increased communication and vigilance at intermediate steps. Workflow became steady and reliable. Introduction of a weekly conference had benefits that compensated for the time commitment. The meeting provided a venue for reinforcing group dedication to maintaining an efficient reporting process. The input of the entire staff was available at case review, which allowed for real-time quality assurance. The latter enabled us to replace a final quality assurance review by a second pathologist, a step that had caused delays earlier.
Streamlining the reporting process carries many benefits. Numerous studies (27-30) have demonstrated that inadequate communication between pathologists and clinical colleagues, including delayed autopsy reporting, accounts for dissatisfaction and may be related to the decline in autopsy rates. Delays in workups occur for a number of reasons and in certain instances may be unavoidable. However, when cases are tracked systematically, workflow is continuous. Delays can be identified in a timely manner and attempts made to reduce them. By being current on the progress of each case, pathologists are able to respond more easily to the queries of clinicians and families. Unrealistic expectations among colleagues can be managed as well. (29) By reducing our time to completion, we were able to improve the reporting process in our laboratory and meet national standards. This program has proved sustainable 15 months after initiation. Increased efficiency and timeliness of autopsy reporting benefit pathologists and clinicians and enhance the care of our families. These techniques may be applicable to other autopsy services with prolonged reporting times. They may be applicable to other laboratory functions as well.
Several individuals contributed significantly to the success of this process: Chad Blanchard, BA; Brent Seeley, BA; Raj P. Kapur, MD, PhD; Kathleen Patterson, MD; Robyn Reed, MD, PhD; Joe C. Rutledge, MD; Karen Krause, BS, HT(ASCP); and Eda DeRooy, CMA.
(1.) Commission on Laboratory Accreditation. Laboratory Accreditation Program: Anatomic Pathology Checklist. Northfield, IL: College of American Pathologists; 2006.
(2.) Chalice R. Improving Healthcare Using Toyota Lean Production Methods. 2nd ed. Milwaukee, WI: ASQ Quality Press; 2007.
(3.) Napoles L, Quintana M. Developing a lean culture in the laboratory. Clin Leadersh Manag Rev. 2006;20(4):E4.
(4.) Dickson EW, Singh S, Cheung DS, Wyatt CC, Nugent AS. Application of lean manufacturing techniques in the emergency department [published online ahead of print August 22, 2008]. J Emerg Med. doi:10.1016/ j.jemermed.2007.11.108.
(5.) Raab SS, Andrew-Jaja C, Grzybicki DM, et al. Dissemination of Lean methods to improve Pap testing quality and patient safety. J Low Genit Tract Dis. 2008; 12(2):103-110.
(6.) Viau M, Southern B. Six Sigma and Lean concepts, a case study: patient centered care model for a mammography center. Radiol Manage. 2007;29(5):19 28.
(7.) Weinstock D. Lean healthcare. J Med Pract Manage. 2008;23(6):339-341.
(8.) McHaffie H. Crucial Decisions at the Beginning of Life. Oxford, England: Radcliffe Medical Press; 2001.
(9.) Lyon A. Perinatal autopsy remains the "gold standard". Arch Dis Child Fetal Neonatal Ed. 2004;89(4):284F.
(10.) Snowdon C, Elbourne DR, Garcia J. Perinatal pathology in the context of a clinical trial: attitudes of bereaved parents. Arch Dis Child Fetal Neonatal Ed. 2004;89(3):208F-211F.
(11.) Laing IA. Clinical aspects of neonatal death and autopsy. Semin Neonatol. 2004;9(4):247-254.
(12.) Opitz JM. The Farber lecture--prenatal and perinatal death: the future of developmental pathology. Pediatr Pathol. 1987;7(4):363-394.
(13.) Mueller RF, Sybert VP, Johnson J, Brown ZA, Chen WJ. Evaluation of a protocol for post-mortem examination of stillbirths. N Engl JMed. 1983;309(10): 586-590.
(14.) Meier PR, Manchester DK, Shikes RH, Clewell WH, Stewart M. Perinatal autopsy: its clinical value. Obstet Gynecol. 1986;67(3):349-351.
(15.) Valdes-Dapena M. The postautopsy conference with families. Arch Pathol Lab Med. 1984;108(6):497-498.
(16.) McDermott M. The continuing decline of autopsies in clinical trials: is there any way back? Arch Dis Child Fetal Neonatal Ed. 2004;89(3):198F-199F.
(17.) McManus BM, Suvalsky SD, Wilson JE A decade of acceptable autopsy rates. Arch Pathol Lab Med. 1992;116(11):1128-1136.
(18.) Committee on Genetics. ACOG Committee opinion no. 383: evaluation of stillbirths and neonatal deaths. Obstet Gynecol. 2007;110:963-966.
(19.) Burton JL, Underwood J. Clinical, educational, and epidemiological value of autopsy. Lancet. 2007;369(9571):1471-1480.
(20.) Adickes ED, Sims KL. Enhancing autopsy performance and reporting. Arch Pathol Lab Med. 1996;120(3):249-253.
(21.) Baker PG, Zarbo RJ, Howanitz PJ. Quality assurance of autopsy face sheet reporting, final autopsy report turnaround time, and autopsy rates. Arch Pathol Lab Med. 1996;120(11):1003-1008.
(22.) Liker JK. The Toyota Way. New York, NY: McGraw-Hill; 2004.
(23.) Womack JP, Jones DT. Lean Thinking. New York, NY: Free Press; 2003.
(24.) Ben-Tovim DI, Bassham JE, Bennett DM, et al. Redesigning care at the Flinders Medical Centre: clinical process redesign using "lean thinking". Med J Aust. 2008;188(suppl 6):27S-31S.
(25.) Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med. 2006;1(3):191-199.
(26.) Stankovic AK, DiLauri E. Quality improvements in the preanalytical phase: focus on urine specimen workflow. Clin Lab Med. 2008;28(2):339-350.
(27.) Bove KE, Iery C. The role of the autopsy in medical malpractice cases, II: controversy related to autopsy performance and reporting. Arch Pathol Lab Med. 2002;126(9):1032-1035.
(28.) Sinard JH, Blood DJ. Quality improvement on an academic autopsy service. Arch Pathol Lab Med. 2001;125(2):237-245.
(29.) Zarbo RJ. Determining customer satisfaction in anatomic pathology. Arch Pathol Lab Med. 2006;130(5):645-649.
(30.) Zarbo RJ, Nakhleh RE, Walsh M. Customer satisfaction in anatomic pathology: a College of American Pathologists Q-Probes study of 3065 physician surveys from 94 laboratories. Arch Pathol Lab Med. 2003;127(1):23-29.
Joseph R. Siebert, PhD
Accepted for publication February 23, 2009.
From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington and the Department of Pathology, University of Washington School of Medicine, Seattle.
The author has no relevant financial interest in the products or companies described in this article.
Presented in part at the fall meeting of the Society for Pediatric Pathology, Louisville, Kentucky, September 4, 2008.
Reprints: Joseph R. Siebert, PhD, Department of Laboratories, Seattle Children's Hospital, 4800 Sand Point Way NE, PO Box 5371/A-6901, Seattle, WA 98105 (e-mail: email@example.com).
Table 1. Autopsy Reporting and College of American Pathologists (CAP) Guidelines CAP Achieved Achieved Deadline, (a) Before After Task Workdays CPI, (b) % CPI, (c) % Provisional anatomic diagnosis 2 26 87 Most autopsy reports 30 17 72 All autopsy reports 60 71 100 Abbreviation: CPI, continuous performance improvement. (a) Data reprinted with permission from the College of American Pathologists. (1) (b) N = 47 cases. (c) N = 47 cases. Table 2. Potential Delays in Autopsy Reporting Level and nature of demands on local practice Delays in obtaining autopsy permit, clinical history, or other documentation Inherent difficulty of case Medical education of trainees (medical students, residents, fellows) Using academic approach to autopsy report, with extensive research and discussion of findings Need for and efficacy of ancillary testing Microbiology Biochemical testing Cytogenetics Molecular testing (eg, mutational analysis) Other tests Instrument malfunction Queues Delays at tissue or document level (increased when trainees are involved) Pending write-up/review of clinical summary and gross findings after dissection is completed Pending review of microscopic slides (gross examination completed and microscopic slides cut) Pending write-up/review of microscopic findings after slides are examined Pending write-up/review of neuropathologic findings Pending write-up/review of final report Delay in completing internal quality assurance review Personnel issues Delays in communication Scheduling difficulties Illness or other staff absence Table 3. Results of Physician Survey After Continuous Performance Improvement Survey Question Respondents, (a) % How would you compare the overall content of recent reports to that of earlier ones? Better 71 Worse 0 The same 29 When are you receiving reports? Sooner than before 85 Later than before 0 No change 15 Did the report address the salient features/clinical issues of the case? Yes 100 No 0 Did the report contain unexpected information? Yes 23 No 77 Comment: "Unexpected in a positive way (ie, unanticipated diagnoses), not inappropriate in formation." Did you find the report confusing in any way? Yes 0 No 100 Did the report aid significantly in counseling the family? Yes 100 No 0 Overall, are you satisfied with the amount of communication regarding autopsies? Yes 93 No 7 Comment: "I'd like to see some form of automated message that alerts me to when I should check the hospital computerized information system for the report." Overall, have you noticed changes in the functioning of the autopsy service? Changes are better 71 Changes are worse 0 No change 29 (a) N = 15 respondents (78% of 19 physicians polled). Table 4. Application of the Toyota Production System to Autopsy Reporting (a) Toyota Principle Benefits Establish long-term Workers "on same page"; culture can be philosophy created or affirmed during workshop and reaffirmed at weekly conferences Define "value" Targets for improvement and standards for (to recipient of operation are established service) Identify value-added Essential steps are identified; those that steps in work-flow do not add value to the process are eliminated Map value stream Creating a diagram of all activities in the reporting process allows workers to understand what may be a complex process and to institute appropriate modification(s) Eliminate waste When the system works smoothly, problems are quickly apparent and can be corrected Seek even workflow Avoiding "stop-start" working style eliminates delays, permits reliable scheduling of staff and tasks Eliminate unevenness Work is not batched, but performed in workflow continuously; this reduces bottlenecks and potential rework Eliminate overburden Eliminates or reduces last-minute requests; on people improves and maintains staff morale Use visual controls Flow sheets and display boards allow one to quickly understand work status and take steps to correct deficiencies Maintain improvements Efficient reporting system requires efficiency in other areas of laboratory as well (a) Adapted with permission from Chalice, (2) Liker, (22) and Womack and Jones. (23)
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