1. turnaround times for Mott hospital cases (i.e. patients < 18 yrs) reflect an uncontrolled process Title: Creation of pathology frozen section laboratory in Mott Owner: Anatomic Pathology (author Jeffrey L Myers, MD) Background: Currently pathology services for Mott patients are provided at a distance from UH. This results in significant quality shortfalls including lost and delayed specimens, delayed turnaround time for intra-operative consultations, and frequent gaps in communications at operational and faculty levels. Goal: Decrease reporting delays and defects in specimen identification for Mott pathology specimens. Reduce intra-operative waits & delays for Mott OR patients who might benefit from rapid pathology consultation. Recommendations: 1.A regularly scheduled pediatric pathology rotation that includes participation of designated faculty, residents and fellows 2.Dedicated space adjacent to Mott hospital ORs to provide opportunities for improved layout and flow Analysis/root cause: Investigation/current state: Next steps: approve space and budget design and implement requisition form activate “IP” prefix in PathNet Plan: 1.A pediatric pathology rotation will be created and staffed weekly by designated AP faculty (owners: Jeff Myers and Robert Ruiz) – April 2008 2.Residents and surgical pathology fellows will be scheduled for pediatric pathology rotations (owners: Joe Fantone and Barbara McKenna) – July 2008 3.Appropriate educational tools and competency measures will be created for participating faculty and trainees (owner: Robert Ruiz) – July 2008 4.Broader faculty participation in support of interdisciplinary conferences (owner: Robert Ruiz and Jeff Myers) – July 2008 5.Space will be identified with appropriate adjacencies for receiving and gross processing of specimens received from Mott hospital ORs, including those received for rapid intra-operative consultation (owners: Women’s Hospital backfill project team) – January 2008 6.Space will be appropriately equipped for gross processing, frozen section diagnosis, and signout of cases assigned to the pediatric pathology rotation (owners: Jeff Myers, Robert Ruiz, Craig Newman, Marty Lawlor) – July 2008 7.Appropriate procedures and processes will be developed for laboratory staffing and specimen transportation (owners: Christine Rigney, Theresa Russell, Craig Newman, Dan Visscher) – July 2008 8.A unique requisition form will be implemented to uniquely identify specimens received from Mott Hospital ORs (owners: Robert Ruiz, Craig Newman, Dan Visscher, Debbie Woodard) – April 2008 9.Specimens received from Mott hospital ORs will be accessioned as “IP” cases and assigned to the pediatric pathology rotation (owners: Kathy Davis, Christine Rigney, John Perrin) – April 2008 1,180 cases in 6 months (JUL-DEC 2006) from Mott; estimated annual volume 2,360 cases most in “general” pediatric surgical pathology (IF, IS) or GI (GA) pathology signout categories multiple “sentinel events” for pathology specimens transported from Mott ORs to UH pathology laboratory specimen sent from Mott OR for frozen section arrived 45 minutes later from UH OR; how specimen traveled from UH path lab to UH OR and back again remains unknown resected rhabdomyosarcoma sent fresh for tumor protocol on a Friday afternoon languished in Central Distribution at room temperature until following Monday liver biopsy intended for “rush” processing on a weekend was discovered 2 days later idling at Mott OR desk intra-operative consultations with pathology are rare events, and when requested result in significant delays (e.g. recent request for intra-operative consultation for ciliary motility took approximately 1 hour per op note) Mott hospital specimens scattered across multiple pathology rotations involving multiple different faculty and trainees no standard process for low volume specimens & communication of results