The Department of Pathology & Laboratory Medicine has placed great effort into our Quality Reboot over this past year. A highlight of these achievements include interdepartmental relationships, the Quality Culture and Education Committee, a focus on patient safety, and curriculum updates.
Interdepartmental relationships are the foundation of collaboration. I would like to spotlight some of the department’s collaborative efforts and projects:
The Quality Culture and Education Committee (QCEP) is committed to improving the culture of quality throughout the Department of Pathology and Laboratory Medicine. By holding quality focused events such as Quality M and M and Quality Day, the committee seeks to elevate awareness, knowledge, and application of Quality Improvement methods for Faculty, Trainees, and Staff. The purpose of Quality M and M is to review adverse or near miss events, and consider the context, root cause analysis and corrective actions as a source of learning and improvement. This event aligns with UCLA Health’s goal of becoming a High Reliability “Zero Harm” organization. At the Quality M and M held in November 2020, two events originating from different areas of the laboratory, were discussed that directly impact patient safety. Dr. Nicole Valenzuela, and a group from the Immunogenetics Center, discussed the implications, root cause analysis and corrective actions of an event of transplant patient samples that were incorrectly accessioned. From Anatomic Pathology, Dr. Ryan Lau discussed the value of an IT project that improved the layout of interpretative comments in cytopathology reports to prevent misinterpretation.
In February 2021, the QCEP Committee held the annual Quality Day which included the 2021 Sarkaria Lecture by guest keynote lecturer Dr. Michael Astion, a clinical pathologist and Medical Director at the Department of Laboratories at Seattle Children’s Hospital and Clinical Professor of Laboratory Medicine and Pathology at the University of Washington. Dr. Astion’s lecture, entitled “Laboratory Stewardship: Achieving Alignment between Patients, Labs, and Payers” as well as the breakout sessions and workshops that followed, were attended by more than 100 people from our department via Zoom. Feedback from the day were extremely positive, highlighting the inclusivity of Faculty, Trainees and Staff, and the wide depth of topics covered in the schedule of events. The QCEP committee also seeks to highlight ongoing quality projects, and projects were presented by Dr. Alyssa Ziman (Division Chief, CP), Virgilio ‘Dindo’ Maglonzo (Flow Lab), Dr. Alex Nobori (Dermatopathology Fellow), Dr. Vishnu Samara (Clinical Pathology Fellow) and Dr. Rebecca Sosa (Immunogenetics Fellow).
Congratulations to Dr. Sophia Liou who is the recipient of a Good Catch Award for September 2020! Dr. Liou, a Surgical Pathology Resident in the department, identified a discrepancy between a patient’s clinical history and the order placed for her breast needle biopsy. The patient's clinical history and the surgical procedure noted that a right mass was to be biopsied. However, the breast needle biopsy was ordered as a left breast biopsy. Surgical pathology staff confirmed that the correct laterality should have been documented as RIGHT breast, and the Pathology records were updated to indicate the correct laterality. Dr. Liou’s critical examination of the documentation in this case was instrumental in preventing patient harm, and is an example of a commitment to the culture of safety at UCLA Health, and within the Department of Pathology.
During this past fiscal year, a new curriculum to support resident/trainee QI education was developed under the leadership of Dr. Yuna Kang. Using the existing structure of the resident lecture series, Dr. Kang invited members of the departments Faculty, Staff and Trainees to give lectures on quality topics that align with the Institute for Healthcare Improvement’s training modules for the Certificate in Quality Improvement. This educational series is also foundational to aid trainees in progress through the ACGME Resident Milestones for Patient Safety and Quality Improvement.
As this fiscal year comes to an end, I look forward to continued opportunities for collaboration, innovation, and excellence in research, education, and clinical care.
Sarah M. Dry, MD
Professor & Chair, Department of Pathology & Laboratory Medicine