[UKNEQAS]

Detailed Information about the Scheme


Organiser

The Organiser of this Scheme changed in the summer of 2008. The new Organiser is Dr Ian Roberts, Department of Cellular Pathology, Level 1, John Radcliffe Hospital, Headley Way, Headington, Oxford.

Tel 01865 220 490 Email ian.roberts@orh.nhs.uk

The previous Organiser was Professor P. N. Furness , Department of Histoathology, Leicester Royal Infirmary, Leicester LE1 5WW.

Tel. (+44)116 2586594 Fax (+44)116 2584573 Email pnf1@le.ac.uk


Supervision

The scheme is run by Dr Robertsbut it is subject to scrutiny by the relevant RCPath Steering Committee (currently chaired by Dr R. McMahon) and by the Histopathology Advisory Panel of the Joint Working Group for Quality Assurance. The running of the scheme is also scrutinised by its own participants at each Participants' Meeting.

Participation

Open to any Pathologist who is (or intends to become) responsible for the reporting of renal biopsies. Participation is voluntary, subject to agreement to circulate cases as outlined below.
Although the scheme is based principally in the U.K., participation is open to pathologists in other countries, subject only to the availability of a postal service sufficiently fast and reliable to maintain the case circulation (as described below).

Collaboration with colleagues

Is not allowed. Consulting colleagues is good practice in routine diagnostic work, but when EQA schemes in histopathology were first established in the UK it was agreed by the RCPath Working Group that EQA responses should represent the work of undividual pathologists, working unaided. Consultation would make the personal feedback system meaningless.

This question was raised again at the Renal EQA Scheme participants' meeting in July 2006, and the original view was reaffirmed. A question was raised as to whether a department could submit a 'team response' if the department was registered with the EQA scheme as a single participant. An overwhelming majority of participants present voted against allowing this. Renal EQA participants are individual pathologists, assessing their own skills.


Circulation of cases

Several `cells' have been set up with up to six pathologists in each. An order of circulation has been drawn up. A set of cases, usually six, is sent to the first pathologist in each cell, with a request to send opinions on the cases to the Organiser and (more importantly) the slides etc. to the next person in the group, by a specified date, 2 weeks after the date when receipt should have occurred. At the start of each circulation every pathologist in the group is informed of the names and addresses of everyone else in the group, and the latest date by which each pathologist should have dispatched the slides to the next. Forms bearing clinical information and spaces for diagnoses are supplied, as is a confidential code number by which replies can be identified (see below).

Participants are invited to comment on the quality of the material circulated, so that feedback on technical matters can be provided to the laboratories which provided the cases.

Delay in passing on the slides is the most likely cause for breakdown of the system. There are four techniques to prevent this:

  1. A computer-generated letter is sent to each pathologist on the date when slides should have been passed on, asking for their immediate dispatch irrespective of whether or not they have been examined, and providing the address of the recipient.
  2. A computer generated letter is sent to each pathologist on the date when the slides should have been received, indicating from whom they should have come and asking the pathologist to contact that person if they have not arrived.
  3. The Organiser attempts to keep at least one spare set of slides to send out if a circulation breaks down irretrievably.
  4. Anyone causing delays is moved to the last slot of the cell in the next circulation.

Selection of cases

Any which might be presented to a renal pathologist for an opinion, including transplants, post mortem cases, metabolic diseases, etc.

To make the cases representative of a typical diagnostic workload, the Organiser writes to individual participants and asks for material from one case to be selected from a defined diagnostic category and within a defined number of biopsies following the receipt of the letter; for example, 'a renal biopsy from the next ten you personally report'. The number can be adjusted to achieve cases with an appropriate mix of `difficulty'. A small number will provide cases representative of a routine workload whereas a larger number will introduce more 'difficult' cases with a greater educational element.

A single case representing a 'splendid example' for educational purposes, or a particularly bizarre case for consultation, is usually included with each circulation. These cases will be clearly identified as such and will not be used for personal analysis (see below).


Material required

This is the decision of the submitting pathologist, but this is not a slide club, so any relevant information available when the original report was sent out should be made available to all participants.

Given the circulation system described above, one set of slides will be seen by six pathologists within 12 weeks. Two concurrent circulations allow the same set of sections to be seen by twelve pathologists within six months. Six duplicate sets permit at least 72 pathologists to see the same cases within six months. It should be possible in most cases to provide six sets of H&E with two conventional special stains; with sectioning at 3 microns or less this would take less than 60 microns of tissue, which is not an unreasonable request. Wherever possible further material should be provided in the form of other sections, photographs or e.m. grids, but where this is not possible all available information and material should be described.

The original diagnosis of the submitting pathologist will not be requested until after the circulation (otherwise the organiser would be unable to participate).


Confidentiality

Each participant is given a code number, known only to the part-time secretary employed on the scheme, which should be entered on the returns to permit a personal statistical analysis of results. The Organiser will undertake to keep all material confidential. To this end he will not himself know the codes. Anyone with a legitimate wish to know the results of an individual Pathologist will therefore have to seek that information from the Pathologist concerned.

A certificate of participation will be issued annually, using the confidential code system. This will identify the recent circulations, the circulations in which a participant returned diagnoses, and any areas of diagnostic practice from which the participant has claimed exemption (e.g. transplant, perinatal).
The certificate will not bear any performance related information; it will merely confirm participation. It can be used to claim CPD points and may be shown to laboratory accreditation inspectors.


Feedback

When all the participants have seen the material from one set of cases the results are collated by the Organiser. Reports giving the range and popularity of the diagnoses offered are sent to all participants, along with any other comments which have been made and the original diagnoses, where available.

There will be a meeting, at least annually, at which cases can be presented (preferably by the submitting Pathologist) and discussed. Personal scores will not be calculated until the appropriateness of each case for EQA purposes has been discussed at such a meeting.

After the meeting, those participants who identified their responses by the code number receive personal analyses indicating the degree of correlation between their diagnoses and the consensus of the group. This is done by the computer and does not involve 'marking' by the Organiser. A histogram giving the distribution of the accumulated 'scores' of each participant is also sent, permitting the participant to see in private how his/her performance compares with his/her peers. The computer program which runs this system is described in the Journal of Clinical Pathology 1993; 46: 357-363. Reprints are available on request. A summary on-line is available by clicking here. The software package is available for other EQA schemes which wish to use it; contact the author on: pnf1@le.ac.uk

Sub-standard performance

In the event of a Pathologist making diagnoses which are markedly at variance with the consensus, the feedback system will make that Pathologist aware of the position, and initially it would be up to him/her to take remedial action.

The GMC requirement that any doctor who suspects that a colleague's performance might put patient care at risk means that the scheme must have a definition of sub-standard performance, and remedial procedures. The current procedure is as follows.


Cost

The organisation of the scheme requires the maintenance of a computer, postage, packing and photocopying costs and a part-time secretary (nominally 1 day per week). The Organiser's time is 'free', but the Department of Health longer supports the scheme directly so a subscription fee is necessary.

The annual subscription rate from April 2008 has been set at 90 pounds sterling per participant per year.

As pathologists often have to cover annual leave for the local renal pathologist, colleagues working at the same address as each full participant may be offered a lower rate; 35 pounds sterling.

Participants from outside the U.K. please add 5 pounds sterling to the above prices.

Participants will also have to bear the cost of postage and the cost of occasionally preparing material for the contribution of a case; currently this is running at less than once every two years. If a request for a case is outstanding at the time the annual invoices are posted (April) then a surcharge of £60 is added to the invoice.


Last Updated: August 2008
Peter Furness, Department of Pathology, University of Leicester.