CALGARY, Nov. 8, 2012 /CNW/ - The Health Quality Council of Alberta
(HQCA) has released its independent review of events that occurred in
anatomical pathology in Calgary in 2010 and 2011, and in Edmonton in
The Calgary events that were reviewed concerned problems in the
preparation of 31 tissue specimens at the Calgary Laboratory Services
Diagnostic and Scientific Centre (CLS DSC) and Rockyview General
The Edmonton events that were reviewed concerned the misinterpretation
of 159 prostate tissue samples by a locum (temporary) pathologist at
the Royal Alexandra Hospital (RAH).
The HQCA's review took a systemic view of the events, meaning that all
findings and recommendations in its final report are related to
system-level improvements associated with the practice of anatomical
pathology in Alberta. The HQCA conducted the review at the request of
Alberta Health Services (AHS) and based on concerns raised by the
Minister of Health regarding assurance of medical quality in anatomical
pathology. Following immediate corrective actions taken, AHS wished to
determine if any further steps were required to reduce the likelihood
of similar events occurring in the future.
"Our report presents findings and recommendations along with required
actions that provide clear directions on how to provide a higher
standard of assurance of quality in anatomical pathology," said Dr.
John Cowell, chief executive officer of the HQCA. "Based on our
analysis of the issues we identified in this in-depth review, we
believe Albertans will receive improved quality of care should the
recommendations from our report be implemented."
"Albertans should have confidence in the work our pathologists do each
day. Our processes are comprehensive and thorough," said Dr. Verna Yiu,
executive vice president and chief medical officer, Quality and Medical
Affairs, Alberta Health Services. "That said, we take this issue very
seriously and we have already started work on implementing the
recommendations made in this review.
"Any changes that can improve patient safety will be made. That is why
we asked for this review - to identify any problems, and fix them."
This review was carried out by an appointed quality assurance committee
of the HQCA and in accordance with Section 14 of the Health Quality Council of Alberta Regulation 130/2006.
The HQCA identified the following issues, and has recommendations with
required actions for each:
1. Automated tissue processing machines - The automated tissue processing machines at the Calgary Laboratory
Services Diagnostic and Scientific Centre (CLS DSC) and Rockyview
General Hospital (RGH) anatomical pathology (AP) laboratories are not
optimally designed to avoid errors.
Recommendation: Alberta Health Services apply 'human factors' science to further
mitigate usability issues associated with the use of AP automated
tissue processing machines.
Undertake a formal human factors evaluation of the automated tissue
processors at the CLS DSC and RGH and other automated tissue processors
throughout the province, including those of contracted laboratory
service providers, and implement the required recommendations. These
recommendations should, where possible, incorporate forcing functions,
if re-engineering of the tissue processing machines cannot be
Set human factors standards for future purchasing of tissue processing
liquids and automated tissue processing machines.
In the long-term, advocate with the manufacturers for redesign of the
automated tissue processing machines and tissue processing liquids
(e.g., formalin and alcohol) to improve usability and lessen the
probability of human error.
2. Calgary Laboratory Services (CLS) organizational structure - There continues to be lack of clarity related to CLS as a wholly
owned subsidiary of AHS and the obligations of both organizations in
that relationship. Recent changes in the CLS board structure and in the
reporting relationship for the CLS Chief Operating Officer (COO) to AHS
have caused more uncertainty for CLS.
Recommendation: Alberta Health Services undertake an organizational review of all
aspects of CLS to provide clear reporting and accountability structures
within CLS and between AHS and CLS.
The organizational review include CLS governance; organizational
structure; the leadership/executive requirements; reporting relationships,
accountabilities, and authority; and the alignment of goals/priorities, funding/budget, communication channels,
and human resources with those of AHS.
Provide educational and mentoring support to individuals (both medical
and non-medical) in leadership roles in CLS and in AHS Laboratory Services. This support
should be aimed at helping individuals determine if they wish to remain in leadership roles and, if
so, to enhance the knowledge, skills, and experience with various aspects of leadership,
including setting priorities, responding to crises, and conflict resolution.
3. Centralization of AP services in CLS - the decision to centralize AP services in CLS remains unresolved.
Recommendation: Alberta Health Services determine if centralization of all AP services
in CLS should proceed from the perspective of patient care, the
clinicians using the service, and the larger AHS AP laboratory
Consider undertaking an operational review to examine service delivery
models, type and volume of work, workload, current and future space and
ventilation requirements, and equipment utilization for AP tissue
processing and interpretation to assist in determining if
centralization should proceed. The operational review would include
effective staff and clinician engagement and communication strategies.
4. Disclosure of harm - The disclosure process following the events that occurred at the CLS
DSC, RGH, and Royal Alexandra Hospital (RAH) was inconsistent and did
not appear to follow a specific organizational model.
Recommendation: Alberta Health Services ensure Laboratory Services staff and clinicians
follow AHS disclosure policies and procedures.
Leadership and physicians in AHS Laboratory Services (including CLS)
receive disclosure training, and evaluation of future episodes of
disclosure is undertaken to ensure consistency with AHS guidelines.
5. Process for recruitment of locum pathologists - A thorough process for the hiring of the locum pathologist to fill a
temporary vacant position at the Royal Alexandra Hospital (RAH) was
Recommendation: Alberta Health Services improve the process for the hiring of locum
Develop a comprehensive approach to the granting of privileges, which
should include checking the working background of the individual and
the amount and type of work completed in a predetermined period.
Develop and apply a systematic approach to the orientation/induction
period of all newly hired pathologists, which would include review by
another pathologist of all tissue specimen interpretations for a period
sufficient to ensure that all types of tissues and an appropriate
number of specimens are reviewed.
6. College of Physicians & Surgeons of Alberta (CPSA) accreditation - The current accreditation processes for AHS-owned, -operated, or
-contracted medical diagnostic laboratories lacks sufficient separation between the organization
conducting the accreditation and the laboratory being accredited.
Recommendation: The CPSA, AHS and Alberta Health collaborate to implement an
accreditation process for public medical diagnostic laboratories that
mitigates the potential for conflict of interest.
Alberta Health assume responsibility for the signing and funding of the
contract for accreditation of public diagnostic medical laboratories
with the CPSA.
The CPSA, as part of the accreditation contract and in addition to the
external pathologist consultant, use assessors from other provinces and
ensure that no assessor reviews a laboratory twice in succession.
7. Performance/assurance of competence of pathologists - The processes that support the regulation and assessment of the
performance of individual pathologists that are conducted by the CPSA
and AHS, respectively, need to be more closely integrated to fully
support performance management and the assurance of competence of
Recommendation: The College of Physicians & Surgeons of Alberta and Alberta Health
Services create and implement a coordinated approach to assessing pathologists' competence and
A provincial working group with representation from the CPSA, AHS
leadership, and pathologists be tasked with the creation of a
coordinated approach to the performance/assurance of competence of
The full report is available at www.hqca.ca.
The Health Quality Council of Alberta gathers and analyzes information
and collaborates with Alberta Health, Alberta Health Services, health
professions, academia and other stakeholders to translate that
knowledge into practical improvements to health service quality and
patient safety in the health care system.
SOURCE: Health Quality Council of Alberta
For further information:
Lisa Brake, Communications Lead
Health Quality Council of Alberta
office (403) 297-4091 cell (403) 850-5067