Best Practices for Diagnostic Excellence in Anatomic Pathology for the Communication of Urgent and Significant Unexpected Diagnoses
By - December 17, 2024
Diagnosis is a critical part of ensuring proper patient care, beginning with the laboratory and extending into all facets of healthcare. However, gaps in the diagnostic process, be they missing, incorrect, or delayed diagnoses, have been shown to be responsible for as much as 59 percent of errors in patient care, according to one nationwide survey.1
To help close the loop on these gaps, the American Society for Clinical Pathology (ASCP) hosted a webinar, “Promoting Diagnostic Excellence by Improving the Communication of Urgent and Significant Unexpected Diagnoses in Anatomic Pathology,” as part of a grant funded by the Gordon and Betty More Foundation in collaboration with CMSS on diagnostic excellence.
The grant convened a diverse group of pathologists for collaborative learning to improve diagnostic excellence around the communication of urgent and significant unexpected diagnoses in pathology and brainstorm to generate ideas for improving the entire process. Here is what they recommend.
The need for diagnostic excellence
While a set of best practices for diagnostic processes for the timely notification of urgent and significant unexpected diagnoses in anatomic pathology already exists as established by the College of American Pathology, there are some gray areas and practice variations the grant seeks to address and help implement, according to Sachin Gupta, PhD, MBA, MLS(ASCPi)MBi, LSSBB, CPHQ, ASCP’s Scientific Director at the Center for Quality and Patient Safety (CQPS), principal investigator of this project, and the moderator of the webinar.
“Pathologists do not clearly understand the difference between urgent diagnoses versus significant unexpected diagnoses,” Dr. Gupta says. “And they are not always clear on the timeline of communicating these diagnoses to the clinician.”
According to one of the webinar presenters, Govind Bhagat, MBBS, Director of Hematopathology at Columbia University Irving Medical Center, “It would be a best practice approach to directly notify medical colleagues of pathologic findings they were not expecting because of the possibility of a loss of information using the traditional diagnostic reporting channels, and the fear of the ball getting dropped by someone.”
Rather than engage in blaming specific personnel when the ball is dropped, the grant suggests that having a set of best practices can reduce medical errors and make sure that communication is a two-way street between clinicians. This is not only good for patient care, Dr. Bhagat says, but “You increase rapport and collegiality and also engender respect. So, the whole system flourishes when good (and timely) communication processes are in place.”
A guide to new best practices
The grant proposal and its collaborative group have laid out eight essential best practices they recommend that covers the following suggestions:
1. Policy
They begin by recommending that every institution have a comprehensive written policy for the communication of urgent and significant/unexpected diagnoses in anatomic pathology, Dr. Gupta says. It should include definitions and examples of urgent and significant unexpected diagnoses (which the grant lays out); requirements for the timeframe to communicate these findings; documentation requirements; and these policies should be developed in partnership with relevant stakeholders.
2. Determination of urgent vs significant and unexpected diagnosis definitions
The need for distinction between urgent and significant and unexpected diagnoses is extremely important and can literally be a matter of life and death.
According to the proposal, Dr. Gupta says, the difference is as follows:
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Urgent diagnosis: A medical condition that poses an immediate health risk to the individual or requires immediate action by the ordering physician.
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Significant unexpected diagnosis: A medical condition that is not clinically expected or is unforeseen and is significant enough to potentially alter patient management or follow-up.
3. Offer Examples
Since many laboratories do not spell out these specific examples of urgent and significant unexpected diagnoses in their policies, the grant recommends that they provide an illustrated list of examples that detail the differences.
4. Methods of notification and communication
Dr. Bhagat points out that part of the problem is that pathologists are doing more and more with less time, reducing the ease of chatting with clinical colleagues about the results of pathologic analyses. Additionally, he says, “There are so many providers within the networks of medical institutions nowadays that sometimes it's not even clear or easy to find out who requested the test and who should be contacted.”
Thus, each laboratory or medical institution should develop solid methods of communication and notification to communicate their findings to the clinicians, Dr. Gupta says. “Should you be emailing them? Should you be calling them? Should you be texting them?”
The grant also recommends the important of “leveraging technology to facilitate automated flagging and notification to communicate these findings.” The goal being to provide “seamless transmission for closing the loop between the pathologist and the ordering provider.”
5. Timeframe
An attempt should be made to communicate both urgent and significant unexpected findings within 24 hours of the diagnosis, preferably on the day of diagnosis, Dr. Gupta explains.
6. Identification of ordering provider
The next recommendation is to clearly identify the ordering provider. “Sometimes, from a pathology standpoint, we don't know who's the ordering provider because it's not clearly stated on the requisition. So, we are providing ideas about best practices on how to identify the ordering provider,” Dr. Gupta explains.
The best practice is to clearly list the ordering provider’s information on the requisition form through a required field.
7. Documentation
Documentation is another key best practice, Dr. Gupta says. “From a compliance perspective, if you are calling somebody with a diagnosis, you need to document it. From a closing the loop perspective, it's very important to document who you communicate with, who you talk with, and what you communicated.”
8. Quality assurance
Lastly, Dr. Bhagat says, the only way to ensure the application of these best practices is “if you have a robust quality assurance and quality improvement program in place where all the diagnostic reports with urgent or significant unexpected diagnoses are identified and reviewed every six months or once a year to determine if people are really adhering to the proposed policies.”
While each laboratory or healthcare institution will have to design methods to track cases for urgent and significant unexpected findings and document communication, it can be done, and information technology can likely help.
Dr. Bhagat finds these best practices to be “a good start” or more like a good continuation of a process that already started a while ago. “I think it's an iterative process. The more you revisit [these best practices] and keep reminding people about the need to think about how to improve the diagnostic journey, how to improve the diagnostic process, it will really enhance patient care.”
The concepts will need to evolve with the changing technologies and the changing times, he added.
Click HERE to read more about ASCP Diagnostic Excellence project and resources
Click HERE to download resource guide with best practices for the effective communication of urgent and significant unexpected diagnoses in anatomic pathology
References
1. Bhagat G, Manuca V, Gupta S. Promoting Diagnostic Excellence by Improving the Communication of Urgent and Unexpected Diagnoses in Anatomic Pathology. ASCP. https://store.ascp.org/productlisting/productdetail?productId=171007325
Jordan Rosenfeld
Contributing Writer