STANDARD 25: Pathology Services

25.1 General

1. If the healthcare organization provides pathology services, it shall be well organized under the supervision of a qualified pathologist.

 25.2 Delivery of Services

1. The pathology scope of service shall be available to the medical staff. This scope of service shall document pathology processes which are determined by the medical staff of the healthcare organization to be:

a) routine;

b) those excluded from routine submission;

c) those surgical specimens exempt from microscopic examination.

2. Microscopic examination shall be performed whenever there is a request by the attending physician, or at the discretion of the pathologist when indicated by the clinical history or gross findings.

3. Sub optimal or inadequate specimens shall not be processed.

NOTE 2 Sub-optimal and/or inadequate specimens are defined as: unidentified, unaccompanied by adequate requisition information, left unfixed or unrefrigerated for an extended period, received in a container/bag with a contaminated outside surface.

4. Incorrectly identified and/or failed (miscreant) pathology diagnoses shall be monitored, measured, analyzed, and reviewed. Results of this monitoring and measuring shall be provided to Quality management oversight.

5. Specimen identity shall be maintained during the processing and examination steps. (See Standard 6).

6. Dissection, description, and histologic sampling of specimen shall be done according to standard of care and pathology under examination.

7. The healthcare organization shall have documented procedure for the safe handling of tissues that may contain radioactive material. These procedures shall be developed in conjunction with the radiation safety officer and shall comply with established safe handling techniques There should be a documented procedure for handling sub-optimal and/or inadequate specimens.

8. Surgical pathology materials shall be retained as required. Their integrity shall be a protected and preserved for retrieval as indicated.

NOTE 3 The retention periods may be extended to provide documentation for adequate quality control and medical care.

9. Incorrectly identified and/or failed (miscreant) pathology diagnoses shall be documented, monitored, measured, analyzed, and reviewed. Output shall be provided to quality management oversight.

25.3 Reporting and Documentation

1. The surgical pathology report shall have a complete patient identifier as determined by the healthcare organization and the requirements of STANDARD 6.

2. The responsible pathologist shall review and approve all reports prior to release. The report shall include:

a) gross descriptions;

b) type and number;

c) weight of specimens;

d) measurements;

e) extent of gross lesions;

f) other relevant information as required to support the pathological diagnosis.

3. The pathology report shall provide data that includes all information sufficient to allow appropriate grading and staging of neoplasms according to standard classification schemes.

4. All reports on routine cases shall be completed and issued in a timely manner commensurate with medical staff requirements.

NOTE 1 In complex or special cases the reporting time may be extended.

25.4 Autopsy

1. The medical staff shall attempt to secure autopsies in all cases of unusual deaths and those of medical-legal and educational interest.

2. Mechanisms for documenting permission to perform an autopsy shall be defined by the medical staff and healthcare organization.

3. The findings from autopsies shall be incorporated in quality management oversight when indicated.

NOTE 1 Some examples of this could include:

a) reporting newly diagnosed infectious diseases to the hospital infection prevention committee;

b) presentation and/or review by institutional quality management system committees;

c) reporting issues related to quality of care to risk management or sentinel event review Committee.

4. A documented autopsy preliminary report of the gross pathologic diagnoses shall be available to the attending physician within 2 working days.