Abstract
The basic tenets of a quality assurance (QA) program are: say what you do, do what you say, prove it, and improve upon it. The bottom line of a QA program is continuous improvement—if you don’t document an activity, how can you measure it and track improvement?
The AAVLD Requirements for an Accredited Veterinary Medical Diagnostic Laboratory (https://www.aavld.org/accreditation-requirements-page), which are based on the ISO/IEC 17025:2017 international standard, state in Article 5.2. “Personnel 5.2.1. The laboratory shall
As a long-time member of the AAVLD Accreditation Committee (1999–2012), and as director (1997–2019) of the AAVLD-accredited Animal Health Laboratory (AHL) at the University of Guelph (Ontario, Canada), a challenge that arose was how to ensure the ongoing competence of pathologists. We do a fine job of proficiency testing (PT) of technicians in the lab, but we have taken on faith, to some extent, that pathologists maintain their competence over time. In the case of technicians, the AHL participates in various external PT programs, including the bacteriology, chemistry/toxicology, endocrinology, and hematology modules of the Veterinary Laboratory Association Quality Assurance Program (VLA-QAP; http://www.vetlabassoc.com/quality-assurance-program/), which is “a global external proficiency testing program specifically designed for veterinary laboratories and hospitals that perform laboratory testing and require an external confidential means of comparing laboratory’s internal test results to those of peers in the veterinary laboratory field.”
The American College of Veterinary Pathologists (ACVP) began time-limited certification (https://www.acvp.org/page/MOC) by which “ACVP Diplomates certified in 2016, or since, must meet minimum Maintenance of Certification (MOC) standards to maintain that certification over a 10-year period.” The program is based primarily on continuing education (CE) and scholarly activities that are documented and auditable, which is all well and good, especially if these activities translate into improved performance and lead to continued competence, but ongoing competence is not assessed objectively and documented.
When filling pathologist positions in veterinary diagnostic laboratories, we typically start with comprehensive position descriptions, select preferably board-certified pathologists (ACVP, ECVP, JCVP), provide CE opportunities, encourage participation in various rounds, and conduct performance reviews, but actually documenting ongoing competence has been a challenge. The question has come to me a number of times of how we have documented ongoing competence of pathologists at the AHL. Our steps to document this activity were eventually captured in an SOP, and include the following:
✓ Monthly peer review of diagnostic cases by our team of pathologists—one biopsy and one autopsy case per pathologist per year, and one hematology and one cytology case per clinical pathologist per year. The final report and slides, or images, are circulated to all pathologists. The anatomic pathology review form used is based (with thanks) on a case review format instituted by Dr. Scott Fitzgerald at Michigan State University (East Lansing, MI, USA), and includes case turnround time (TAT) compared to the published TAT, and, as appropriate, adequacy of gross description, quality and quantity of slides, microscopic description, interpretation of IHC slides and/or other ancillary tests, response to client questions, coding of diagnoses, notification of notifiable hazards, record of communication history, billing, report formatting, and, perhaps most importantly, opportunities for improvement. A similar form is used by clinical pathologists.
✓ Documented participation in histopathology case rounds. At the AHL, these are documented semi-weekly sessions to review interesting and difficult cases—opinions from the group participants may be included in pathology reports to strengthen and support the final diagnosis and comments.
✓ Participation in the quarterly VLA-QAP histopathology, hematology, and cytopathology modules.
✓ For anatomic pathologists, caseload and TATs for postmortem and histopathology cases are tracked on a monthly and yearly basis, with tabulated results continuously available for monitoring by all pathologists.
✓ Semi-annual review by the director of randomly selected anatomic pathology cases (6 autopsies and 4 biopsies) for each pathologist to ensure conformity with a standard report format, billing, and diagnosis coding.
The above process has been refined over the years at the AHL and I think has served us and our clients well. All steps are documented in a written format, and are easily audited, particularly as part of our AAVLD accreditation site visits. Participants find value in the program, and it is sufficiently straightforward and simple that participation is routine and not onerous. Not only does this process meet accreditation requirements, but it has supported excellent service to the clients of the AHL.
The AAVLD Pathology Committee has undertaken several initiatives to provide opportunities for evidence of ongoing competency: pathology guidelines (2009, under review), IHC inter-laboratory comparison (started in 2013, and recommenced in 2022 after having been discontinued for a few years), and histopathology inter-laboratory comparison (to start in 2023). It behooves every veterinary diagnostic laboratory to ensure that it has considered and implemented a quality program for its pathologists—not only in preparation for visits by auditors but in the interest of providing excellent client service.
