Increasing the efficiency of autopsy reporting.
Abstract: * 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.
Subject: Autopsy (Quality management)
Autopsy (Reports)
Pathologists (Powers and duties)
Pathology (Practice)
Medical care (Quality management)
Medical care (Standards)
Author: Siebert, Joseph R.
Pub Date: 12/01/2009
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
Accession Number: 230246905
Full Text: 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.

RESULTS

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).

COMMENT

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.

References

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(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.

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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: joseph.siebert@seattlechildrens.org).
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)
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.