Integrated Analysis of Quality Use of Pathology Program (qupp) Final Reports

Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008)

Description

This program sought to develop a program to identify the reasons for incomplete or incorrect pathology request forms submitted by medical staff in a large teaching hospital in Sydney. This was done using a questionnaire, focus group interviews and audits of pathology request forms.

Grant Recipient

Royal North Shore Hospital

Aims

• 
  to determine the type of errors that can occur in the completion of pathology request forms
  
• 
  to determine the reasons for these errors
  
• 
  to determine the relative importance of these errors
  
• 
  to determine the impact of these errors on laboratory staff.
  

These aims were achieved by this project.

Outcomes

• 
  One hundred and four questionnaires were completed by interns, resident officers, registrars and consultants (342 were sent out).
  
• 
  An audit of 236 randomly selected pathology request forms over a period of one month to determine the type of errors and omissions and their frequency.
  
• 
  An additional 179 request forms completed by interns were also audited. This consisted of two separate audits three months apart to determine the effect of the work environment on the completion of request forms.
  
• 
  An audit of time spent seeking information from clinical staff due to incomplete or inadequate request forms.
  

Findings

Staff Attitude

• 
  The clinical staff did not consider it necessary to complete a pathology request form, particularly clinical and medication details, which showed a major problem with the attitude of the clinical staff towards the pathology request form.
  
• 
  Clinical staff did not understand the impact of incomplete or incorrect pathology request forms on laboratory staff including the extra work required by laboratory staff to find the missing information. There was also corresponding resentment amongst laboratory staff which adversely affected communication between the two staff groups.
  

Time Issues

• 
  One reason for incomplete documentation on the pathology request form was too may sections to be completed which took time to fill in.
  
• 
  The amount of time wasted and therefore cost to the laboratory because of errors in request forms is considerable. Omission of ID of the requestor and requestor contact details are the sections that cause the most waste of time for collectors and laboratory staff.
  
• 
  Laboratory staff spent a considerable amount of time to find the missing or incorrect information on the pathology request form. This means that any improvement in the completion rate and accuracy of pathology request forms will improve laboratory productivity.
  

Errors

• 
  The audit showed six sections on the pathology request form accounted for about 80% of the errors and caused significant problems for laboratory staff. These were:
  
  1. 
     clinical details
     
  2. 
     medication details
     
  3. 
     requestor contact details
     
  4. 
     ID of the requestor
     
  5. 
     ID of the collector
     
  6. 
     collection details.
     

Of these sections, clinical and medication details were the most frequently omitted which have a significant impact on the interpretation and reporting of the result.
Education

• 
  Interns were very good at completing pathology request forms, with the exception of clinical and medication details, at the start of their career. However, their error rate increases over time which indicates that education and feedback are essential to maintain good clinical practice.
  
• 
  Medical staff have a good understanding of the medico-legal aspects of the pathology request form.
  
• 
  Education should target a few key areas rather than cover all sections of the request form.
  
• 
  The work environment does not encourage junior medical staff to correctly complete pathology request forms. They are given little feedback about their performance in the completion of request forms.
  

Recommendations

1. 
   Develop an education program that targets the most important errors or omissions on request forms.
   
2. 
   An education program, which includes laboratory staff, must be given to all medical staff. The error rate in consultants is sufficiently high to warrant providing further education.
   
3. 
   Review the content and format of pathology request forms and decide which sections do not require completion by medical staff. Removing non-essential sections will allow more time for completion of essential sections.
   
4. 
   Review the format of the pathology request form to facilitate completion of the most essential sections.
   
5. 
   Move to electronic request forms which will allow the implementation of mandatory fields.
   

Follow on Initiatives and Projects

• 
  A Best Practice in Pathology Requesting and Reporting Workshop (2009)on page 167 was convened by the Australian Government Department of Health and Ageing to further explore requesting issues with key stakeholders.
  

Areas for Future Consideration

• 
  Review the format and content of pathology request forms.
  

• 
  Investigate implementing an education program which targets the most important errors or omissions on request forms.
  

Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009)

Description

This project sought to undertake a needs assessment to inform the development of a training program and series of training modules focused on maximising the uptake of education and training in the quality use of pathology by general practice (GP) Registrars and International Medical Graduates (IMGs). It adopted the view that improved vocational training in the appropriate use of pathology will assist in addressing the issues faced by GP Registrars in moving from a hospital based training setting to community based general practice, especially since registrars indicated that it was easier to seek advice and feedback regarding pathology use in the general practice environment.

Grant Recipient

University of Adelaide

Aim

• 
  to identify the pathology training needs of GP Registrars and IMGs to inform the development of a training module/s focused on maximising quality use of pathology
  

Objectives

• 
  to undertake a needs assessment to inform the development of a training module focused on maximising the uptake of education and training in the quality use of pathology by GP Registrars and IMGs
  
• 
  to investigate the work undertaken to assess the educational needs of GP Registrars and IMGs in relation to pathology testing
  
• 
  to gain insight into GP Registrars’ and IMGs’ knowledge of pathology testing, their training experience and to identify gaps in their training to assist in designing the Needs Assessment Survey to be disseminated to a wider group of GP Registrars and IMGs
  
• 
  to gain the perspective of pathology providers on the current training needs for GPs and IMGs
  
• 
  to gain an understanding of GP Registrars’ and IMGs’ knowledge of pathology testing, their pathology training experience and to identify gaps in their training.
  

The aim and all objectives were achieved by this project.

Outcomes

• 
  A literature review was conducted to inform the conduct of focus groups, pathology provider interviews and the development of a needs assessment survey.
  
• 
  A qualitative analysis via focus groups with GP Registrars and IMGs to gain insight into their knowledge of pathology testing, their pathology training experiences and to identify gaps in their training.
  
• 
  A qualitative analysis via interviews with pathology providers to gain their perspective on the current training needs for GP Registrars and IMGs.
  
• 
  Information from the focus groups and interviews was used to develop a questionnaire.
  
• 
  A quantitative analysis via a Needs Assessment Survey disseminated to a broader cohort of GP Registrars and IMGs to gain an understanding of their knowledge of pathology testing, their pathology training experiences and to identify gaps in their training.
  

Findings

Literature Review

• 
  This study confirmed there is a lack of pathology training being provided to GP Registrars and IMGs.
  
• 
  The literature review highlighted a lack of training for GP Registrars and IMGs in the area of pathology testing.
  
• 
  The review highlighted a number of areas relating to the quality use of pathology in general practice including:
  
  • 
    Evidence indicates a relationship between GPs’ characteristics and pathology utilisation. For example, female GPs and younger GPs tend to order more laboratory tests.
    
  • 
    Pathology usage is linked to level of training and experience. As the confidence of GP Registrars and IMGs increases, their test ordering behaviours may improve. For Registrars it will develop with knowledge and experience; for IMGs it will develop as they gain a better understanding of the Australian healthcare system. This is also related to confidence and knowledge.
    
  • 
    Additionally, knowledge of clinical guidelines, size of practice and utilisation of specifically designed pathology ordering forms improved quality use of pathology.
    
  • 
    Patient profile can influence pathology ordering for GPs. Patients with a higher level of education requested more pathology tests.
    
  • 
    A number of interventions which range from feedback, education and audits to ordering protocols have been shown to improve pathology ordering. The most successful approaches utilise multifaceted strategies.
    
  • 
    There exists a lack of designated pathology training at the undergraduate and postgraduate levels in Australia and particularly for GP Registrars and IMGs.
    
  • 
    Different groups have different training needs. For example, IMGs require training in the Australian healthcare system, communication skills and clinical management within the Australian setting. Any training module needs to ensure these differences are addressed, while other areas will be similar to the needs of GPs undergoing registrar training.
    
  • 
    A national survey on pathology teaching in prevocational and GP vocational training identified the need for a pathology audit package for GPs.
    

Focus Groups

• 
  The focus group participants and interviews confirmed the existence of gaps in the pathology training being provided to GP Registrars and IMGs.
  
• 
  Most pathology training at undergraduate level was received through case-based or conditioned-based discussions and problem-based learning (PBL).
  
• 
  Most training and experience at postgraduate level was gained through clinical placements in general practice and the hospital setting.
  
• 
  Rural GP Registrars indicated they would like further training on collecting and preserving samples properly.
  
• 
  The focus group participants identified the conditions which appeared to cause the most difficulties in regards to test ordering as:
  
  • 
    rheumatology
    
  • 
    menopausal and infertility problems
    
  • 
    vague illnesses such as tiredness.
    
• 
  The focus group participants identified the tests most difficult to interpret as:
  
  • 
    rheumatology results
    
  • 
    liver function tests (LFTs)
    
  • 
    lipid tests
    
  • 
    hormones
    
  • 
    prostate specific antigen (PSA)
    
• 
  Test results that were mildly elevated and moderately abnormal posed the most problems.
  
• 
  The focus group participants identified supervisors and colleagues as the people they would mainly approach for assistance with test ordering and test interpretation difficulties. They often sought advice from pathology providers, but mostly in regards to test interpretation.
  

Pathology Provider Interviews

• 
  The pathology providers highlighted LFTs, full blood counts, thyroid function tests (TFTs) and reproductive endocrinology as the tests they receive the most calls in regards to assistance with test interpretation.
  
• 
  The pathology providers believed the following tests were overused by GPs:
  
  • 
    TFTs
    
  • 
    PSA
    
  • 
    glycated haemoglobin (HbA1c)
    
  • 
    lipids
    
  • 
    tumour markers
    
  • 
    vitamin B12
    
  • 
    folate tests.
    
• 
  Situations they might receive a call about a test result included:
  
  • 
    a test result is late
    
  • 
    a test result for a patient who has been seen by a GP or specialist outside the practice
    
  • 
    a test result for a GP whose practice is not computerised.
    
• 
  They received the most enquiries from GPs in rural and remote areas, IMGs and older GPs.
  
• 
  They received more calls from GPs to help interpret a test result than for advice on the most appropriate test to order.
  
• 
  The need to have sufficient information on the requesting form, including good contact details for the GP, was highlighted as very important.
  
• 
  All interviewees believed there are gaps in the current medical training regarding pathology including practical aspects such as:
  
  • 
    how specimens are collected
    
  • 
    the timing of specimen collection
    
  • 
    the difference between the first passed specimen of urine and a mid-stream urine
    
  • 
    best practice to culture a wound.
    
• 
  Pathology providers indentified the following areas for inclusion in pathology training for GPs:
  
  • 
    practical sessions on specimen collection and types of specimens
    
  • 
    more education about common tests and their use in screening
    
  • 
    the importance of providing appropriate and sufficient clinical notes on request forms
    
  • 
    specific information about tests/conditions that are applicable to the area in which the GP is working.
    
• 
  Younger doctors and female doctors tended to order more pathology as a group.
  

Needs Assessment Survey

• 
  Pathology training diminishes as participants move through their levels of medical training.
  
• 
  IMGs reported less test interpretation problems. As this cohort were older and graduated earlier than the GP Registrars, this was thought to be associated with their years of experience.
  
• 
  Both groups requested further training, particularly for reproductive hormones including the infertility/pregnancy tests as well as hepatitis serology tests, and more information about new tests and advances in pathology testing.
  
• 
  The case scenario also identified several tests that may be inappropriately used including ferritin, creatine kinase, erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) tests. It is unclear if this is due to a lack of understanding on the use of these tests or a result of panel ordering.
  
• 
  The participants identified several conditions/symptoms which caused them the most problems in regards to pathology testing. Participants had the greatest difficulty with test ordering and test interpretations for conditions/symptoms that are vague and/or where there were no guidelines or decision support systems available. In contrast, the least difficulty was reported for conditions such as diabetes, lipids and urinary tract infections where clear management guidelines are available.
  
• 
  Presentations of weakness/tiredness and menopausal symptoms/complaints were reported as conditions causing the most problems.
  
• 
  The format in which participants would like to receive further training included case studies, short seminars or conferences and on-line learning resources, with case studies being most favoured by IMGs.
  

Recommendations

1. 
   A training module/s to include information on the application of the tests identified as causing the most difficulties.
   
2. 
   A training module/s to include strategies and available evidence-based resources to manage conditions/symptoms where no guidelines currently exist. The module also needs to include information to help raise awareness about the differences between pathology testing in the hospital and GP setting. This could include untilising ‘a wait and see’ approach, communicating effectively with patients and advocating the importance of taking a detailed history.
   
3. 
   The training module/s be provided in multiple formats and designed to suit the education material being provided.
   
4. 
   GP Supervisors advised of the pathology training needs for GP Registrars and IMGS, and provide them with the education and resources to assist them in this knowledge transfer.
   
5. 
   Establish a working party, including a GP Supervisor and a pathology provider, to develop the training module/s for implementation through GP training providers. It is important that the module/s be continually updated to reflect the best evidence-based resources available, and that the participant’s pathology training needs are periodically evaluated.
   
6. 
   Areas/topics suggested by this project’s focus group and interviewees for further pathology training include:
   
   1. 
      practical sessions on collecting and preserving samples
      
   2. 
      common tests and their use in screening
      
   3. 
      what is covered under the Medicare Benefits Schedule (MBS)
      
   4. 
      how to find pathology information all in one spot
      
   5. 
      information on specific tests/conditions that are applicable to the area in which the GP is working.
      
7. 
   Pathology providers would like a session on providing appropriate and sufficient clinical notes on request forms.
   
8. 
   Supervisors can play a key role in providing further pathology training.
   

Follow on Initiatives and Projects

• 
  Project outcomes were promoted at the Best Practice in Pathology Requesting and Reporting Workshop on page 167.
  

Areas for Future Consideration

• 
  Possible development of a training program/modules to be provided to GP Registrars and IMGs, and the need for a training module/s.
  
• 
  Develop fact sheets covering the area’s highlighted in recommendation no. 6 above.