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Cytopathology and more: Know where the deficiencies and dust hide

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Lydia Pleotis Howell, MD

May 2013—Accreditation inspections are inevitably stressful events. Having a colleague you’ve never met walk through your lab with a checklist looking for how you’ve slipped up reminds me a bit of my mother’s first visit to my apartment when I was a newlywed. I had cleaned everything, including every nook and cranny that weren’t part of my usual routine. I even bought a new shower curtain to ensure no possible hint of mildew. I thought the place looked terrific and that my high level of preparation would surely be sufficient to meet my mom’s white glove standards. Little did I expect that she would peer down the shade of my living room lamp shortly after arriving and remark that I really should dust my light bulbs.
It is hard to ever be fully prepared for a June Cleaver mom or to read the mind of a CAP inspector. Fortunately, deficiencies in cytopathology are relatively infrequent and don’t involve eliminating dust on light bulbs. Nonetheless, being aware of the top three checklist items that are most often cited as phase one and two deficiencies can be helpful in your inspection preparation and will assist you in avoiding pitfalls.

According to the CAP’s data from inspections occurring between Nov. 1, 2011 and Nov. 1, 2012, the most common cytopathology checklist item for a phase one deficiency was CYP.07690, which requires that 90 percent of reports on routine nongynecologic cytology cases be completed within two working days of receipt by the laboratory performing the examination. Citations for this checklist item constitute four percent of all the phase one deficiencies. It is important to note the word “routine” in this requirement, and to be sure you are collecting statistics only on your routine cases. Cases that involve special processing or extra studies such as immunohistochemistry or molecular analysis are not considered routine, and longer turnaround times are acceptable. However, the lab must also provide a reasonable targeted reporting time for the non-routine cases. Documenting turnaround time may not always be as easy as you’d like it to be due to constraints in your laboratory information system, which may not be able to distinguish working from non-working days, or routine from non-routine cases. The CAP inspector will therefore not require continuous monitoring and will accept periodic auditing of reports as an acceptable alternative.

The second most common phase one deficiency in cytopathology (2.7 percent of all deficiencies) involves CYP.06450, which requires a policy regarding communication of significant and unexpected cytopathology findings and documentation that such communication is occurring. Laboratories can create their own list of significant and unexpected findings that fits their own practice environments, resources, and client needs. We all know how difficult it can be to contact busy clinicians to communicate unexpected findings. Fortunately, the CAP accreditation checklist recognizes this difficulty; this checklist item notes there must be “reasonable” efforts to ensure these diagnoses are received by a clinician and that a variety of means can be employed, such as phone calls, pager, or other notification. The need to document the date the notification occurred is another common pitfall in this requirement. Notification methods such as e-mail or messaging through the electronic health record can make it easier to meet all aspects of this checklist requirement since a dated and traceable message can be sent that is available at the clinician’s convenience.

Close behind at No. 3 among the phase one deficiencies (2.3 percent of all) is a fairly new checklist requirement that was added in July 2011, CYP.01650, which requires that laboratories have a policy listing specimens that an institution may choose to exclude from routine submission for cytologic examination. The laboratory must also provide documentation that this list of exclusions was made in collaboration with the institution’s medical staff to ensure that the needs of laboratory and clinician are considered. Since not all laboratories are part of a larger institution or health care organization, this checklist requirement does not apply universally to all laboratories. Additionally, this checklist item does not obligate laboratories to create a list of exclusions; laboratories are fully able to require cytologic evaluation on all specimens, if they so choose.

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