Introduction

About Workload

Pathologists are knowledge workers, not labour workers, which makes their productivity difficult to measure in a consistent manner. Specifically, the nature of their job is to solve a medical problem (make a diagnosis by interpreting pathological changes in tissue) using the knowledge that they have, rather than carry out predefined repetitive and invariable tasks. It is easy to quantitate a manual worker’s workload, as the product of their labour is visually apparent. However, workloads are not immediately obvious with knowledge workers. The quality of a knowledge worker’s output is at least as important as, if not more important than the quantity1. Furthermore, the output (diagnosis) is workflow independent; it cannot be determined solely by the number of slides to be interpreted, as the nature of the disease may vary considerably from patient to patient. There are also continual increases in the level of information and knowledge required, such as understanding of biomarkers and molecular tests, to inform good patient management in the era of personalized medicine. A study by Warth et al.ii showed that the evolution of diagnostic procedures over the last decade has resulted in a 60% increase in slide numbers per case, doubling of immunohistochemistry procedures, and more than tripling of molecular analyses2.

The purposes of workload measurement are as listed in the RCP guidelines 2nd edition5:

  • To support pathologists in providing a mechanism for ensuring that an individual’s sessional workload is reasonable, safe and practicable but not excessive, recognising that it is in the public interest to reduce errors related to overload, whether sustained or over short periods
  • To reassure the public that the appropriate workforce resources are devoted to the reporting of pathology specimens
  • To enable the equitable distribution of work amongst pathologists within a department, having regard to the varying complexities of differing specimen types, as well as the administrative and managerial work of consultants both locally and in the wider interests of the public
  • To facilitate workforce planning such as schedule creation
  • To assist pathologists in job planning and in the preparation of supporting documentation for appraisal

About CommonPaths

Data mining can provide valuable support to the effective management of pathology facilities. The introduction of new tests and technologies in anatomical pathology will increase the amount of specimens to be processed, as well as the complexity of pathology processes. In order for predictive analytics to address managerial challenges, it is important to pinpoint the areas where pathology managers would most benefit from analytics capabilities. The real-time use of operational data have the potential to increase quality and to reduce costs, contributing both to an increase in facility performance and effective management.

Commercial pathology systems record and track individual specimens. CommonPaths provides untapped data analytics and data mining capabilities by automating data extraction from these clinical systems in order to monitor key phases in pathology processes providing a fine-grained overview of the performance of the department in terms of cases that are within or that exceed predetermined processing targets, namely:

  • Number of pending and grossed cases
  • Number of pending and cut blocks
  • Number of pending and routed slides

It also tracks workload using 5 separate workload management systems (WMS) based on case volume and specimen complexity that are grouped by specialty, subspecialty and individual pathologists on a daily, monthly and annual intervals. There are several published proposals for pathologists’ WMS, we decided to measure four simultaneously, the Canadian Association of Pathologists (CAP-L4E)3, the Ontario medical association Work2Quality (W2Q)4, the United Kingdom Royal College of Pathologists (RCP-UK)5, the American Current Procedural Terminology (CPT) schedule of unit values (SUV)6 and Code5 (see below).

About Code5

Choosing which WMS to follow is challenging due to the following reasons:

  • The workload values of each WMS are different, and each WMS shows a bias for certain subspecialties, specimens or procedures7
  • There a disagreement among pathologists to which WMS is accurate
  • There is a need for a system that estimates workload prospectively for daily use at the time of case assignment (the RCP-UK is prospective but not robust)

Until these issues are addressed, we recommend using the average of all 4 WMS, hence called code5, since the average is the closest to the truth. It is calculated for each specimen type individually based on the average of the accumulated units for all 4 WMS from nearly 400,000 specimens collected at our institute. It is an all-inclusive code for the specimen, slides, SS, IHC, orders and reviews (except for frozen section that has its own Code5 units). The units of Code5 are based on the length of unintereupted time to complete each specimen of the case, calculated by the seconds, but displayed as minutes. The workload of a full-time pathologist (1 FTE) is 360 minutes per workday (6 hours), or 77400 minutes per year for an annual 215 workdays. You can review your own data and validate how Code5 compares to the other 4 WMS in the "workload" report, and for each specimen in the “specimen” report. Once your installation has sufficient data, Code5 will be re-calculated annually based on your own institutional practice results.

CommonPaths Essentials

The accuracy of workload measurement depends on 2 factors:

  • Specimen templates: CommonPaths relies on specimen templates to assign workload units. For example, medical renal biopsies and surgical renal biopsies should use different specimen templates
  • Order templates: CommonPaths relies on order templates to request levels, SS or IHC to assign workload units. There are 4 sub-categories to special stains, and 4 sub-categories to IHC. Some orders are given workload units once per specimen, other orders are given workload units only if requested by the pathologist after receiving the slides. Therefore, each order should be linked to its specimen and the date & time the order was placed needs to be specified.

CommonPaths Flavors

There are 3 versions of CommonPaths to accomodate different installations based on the department size:

  • Client-Server is an unlimited multi-user application for large departments (6+ pathologists). The analytical software resides on a single application server, the relational database resides on the database server, and the thin-client reports viewer is installed on each user existing desktop
  • Standalone is a single user application for small departments (1-5 pathologists). It combines the analytical layer, the database layer and the reports viewer in a single application running on 1 dedicated desktop. One personnel will use the application and exports the reports to other users via email or paper. The station must be located in the histology lab for the routing report to be useful
  • Data viewer is an off-site service where you provide me with asynchronous data sets to be analyzed at my servers, and you will receive unlimited multi-user, thin-clients, read-only reports viewers to be installed on each user existing desktop. This format offers historical workload data only, and requires manual updates every 3-6 months. This solution is a last resort if your hospital refuses a local installation

References:

  1. Drucker, PF. Knowledge-Worker Productivity: The Biggest Challenge. California Management Review. 1999;41:79-94
  2. Warth A, Stenzinger A, Andrulis M, Schlake W, Kempny G, Schirmacher P, Weichert W. Individualized medicine and demographic change as determining workload factors in pathology: quo vadis? Virchows Arch. 2016;468:101-108
  3. Canadian Association of Pathologists, Workload Measurement Guidelines (2014). Available from: https://www.cap-acp.org/cmsUploads/CAP/File/CAP-ACP%202014%20Workload%20FINAL.pdf
  4. Work2Quality Guidelines for Workload Measurement in Pathology Professional Practices version 1.2 (2012)
  5. The Royal College of Pathologists. Guidelines on staffing and workload for histopathology and cytopathology departments, 4th edition (2015). Available from: https://www.rcpath.org/uploads/assets/uploaded/03d44fb1-ccd8-4f1f-bd1447d3fdf195b0.pdf
  6. The Centers for Medicare & Medicaid Services, CMS (2018). Available from: https://www.cms.gov/apps/physician-fee-schedule-documentation.aspx
  7. Halwani F, Halil A, Ramsay T, Banerjee D. Comparison of four commonly used guidelines for workload measurement in pathology. Canadian Journal of Pathology 2019;11(2);28-40