Guideline
Subject:
Approval Date:
Review Date:
Review By:
Number:
CPDP - Quality Activities
November 2008, November 2013
November 2015
BPPQ
3/2008
The College’s Continuing Professional Development Program (CPDP) requires participants
to do at least 10 hours per annum of Quality Activities which contribute to improved patient
outcomes or to improving the standards of pathology practice. In addition to quality
assurance activities this may include professional, governance or accreditation activities.
Quality Activities that can be included are listed in the CPDP book and are as follows:
Participation as RCPA examiner. e.g. Contribution of exam questions, marking written
papers; viva examiner.
Participation in quality assurance activities, including QAP or self assessment programs.
Includes management review of QAP results either individually or as part of a group.
Quality Assurance Project – This includes projects devised by individual pathologists to
examine a particular aspect of their practice, or the laboratory more generally, with the
aim of improving or confirming satisfactory practice. For example, an anatomical
pathologist may decide to review their reports from liver cases over the last six months to
see if they reach the same conclusions as previously, to see if the actual wording of the
reports could be improved for clarity and to see whether use of a template might assist.
Laboratory visit for benchmarking purposes.
Membership of a QA committee – Includes not only formal QA committees, but ethics
committees, infection control committees and drug committees.
Participation in peer review or laboratory audit, incl. NATA inspections, ACHS surveys
Participation in national quality activities e.g. National Institute of Clinical Studies,
Australian Patient Safety Foundation.
Participation in incident monitoring e.g. KIMMS.
Clinical or case audit, including slide reviews.
Preparation for expert witness or presentation of forensic evidence in court.
Development or assessment of materials, relevant to pathology, for education and
training for RCPA or other organisations.
Examples include review of external materials for suitability for use by RCPA; de novo
development of training modules or slide sets.
Participation in committees, working groups of the College; acting as College nominee or
representative on committees of regulatory or other institutional bodies; or provision of
individual input to specific issues e.g. participation in credentialing committees, MSAC.
Other activities not listed above.
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Advisory Committees have recommended that quality activities should be individually
tailored and linked to actual work in various areas rather than generic, and should reflect
involvement in management where relevant.
It was also noted that 70% of incidents relate to pre-analytic or post analytic phases of
testing and that this should be a focus of quality activities. The Key Incident Monitoring and
Management System (KIMMS) QAP is reflective of this focus.
Quality activities could be assessed in a risk management matrix comparing likelihood of
event (rare to frequent), with outcomes (minor to catastrophic) to give guidance as to the
activities to review.
The following additional quality activities have been proposed.
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Attendance at CME meetings and workshops (not just conferences)
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Teaching relevant professional skills, especially to College trainees.
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Publications, especially about diagnostic matters (rather than “basic” research).
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Participation in international and local (eg hospital or laboratory) quality activities (as well
as national ones) specific to aspects of their discipline.
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Professional contribution to discipline related groups e.g. Australia and New Zealand
Society of Blood Transfusion (ANZSBT) for pathologists with a role involving transfusion.
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Quality related administrative and management responsibilities (eg investigation of
adverse events within a laboratory).
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For anatomical pathology, internal audit is seen as the most appropriate quality activity
and mechanisms for undertaking internal audits are being explored through a survey of AP
Fellows. Methods already known to be in use include:
• Random audit – fixed % of cases re-read ‘blind’ and compared with original diagnosis
• Targeted audit e.g. review all cases of a given disease category over a specified time
• Routine audit e.g. review diagnoses at CPC meetings; review all amended reports
• Incident reporting – record all adverse diagnostic incidents
(It should be noted that internal audit results are only considered worthwhile if collated
over time to allow monitoring and benchmarking.)
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