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Cytopathology report 12-03-2013 By; Sejojo Phaaroe. Head of cytology Section March 2013 1
List of contents 1. preamble 2. goal 3. justification 4. introduction 5. achievements and results 6. challenges 7. way forward 2
Cytopathology report 12-03-2013By; Sejojo Phaaroe. Head of cytology Section SECTION 1 1.1 Preamble: The Ministry of Health (MOH) of the Kingdom of Lesotho is mandated to coordinate national healthcare, and oversee the operation of an effective Health policy, within its departments so is the Laboratory and its sections such as Cytology Laboratory. The broad mandate of the MOH seeks to: Contribute to increased life expectancy as well as quality of life, Reduce infant and child morbidity and mortality rates, Reduce the maternal mortality rate , To control and prevent communicable diseases such as tuberculosis, acute respiratory infections, diarrhoea and AIDS, Minimise the impact of deteriorating socio-economic conditions on marginalized groups such as geriatrics, children, paupers and disabled persons, Empower community based structures in the delivery of preventive and basic curative services for health. HIV and AIDS are a workplace issue and needs to be treated like any other occupational hazard. Health Workers (HWs) and managers at all levels thus need to be sensitized to workplace issues related to HIV/AIDS. The strategies pursued towards this mandate can be summarised as follows: Promote access to quality preventive, curative, rehabilitative and referral services Implement the sector policy Improve development & maintenance of health infrastructure, equipment, Improve the capacity of health personnel Improve management systems within the sector Engage in evidence based research which benefit the impact sector analysis strategy It is imperative to measure Cytopathology performance indicators against the whole Ministry’s , and the Laboratory expected performance levels which are contained within the National RH Cancer Guidelines 2008-2012 which was build , adopted with guiding principles of ownership, integration and sustainability by the stakeholders such as Family Health , Laboratory Services, planning and Finance, CHAL, Human resource etc. Measurable Indicators and progress report will be extracted from the expectation of what is the Main function of a Cytopathology Unit in Lesotho? What is the main strategic planning of the Ministry of Health and Social Welfare, under Laboratory services towards Cytology Laboratory Services, National RH Cancer Guidelines 2008-2012 , and development? 3
1.2 Goal: To reduce the disease burden by screening and diagnosis due to inflammatory conditions Benign , Malignant conditions in the Cervix , and some small percentage of Fine needle aspiration biopsies and effusions we receive in our laboratory. The program implementation should be measurable with indicators to include disease burden 1.3 Justification: The Sensitivity, specificity, success and cost effectiveness of a running program is dependent on indicators such as what is expected in the strategic planning, the screening rate, success, follow up rate, number of people treated, treatment success rate, treatment failure rate , cost of all interventions( smear taking, Management QMS, technical QMS processes , screening, follow up , reporting) . The screening program of any disease is useless in the absence of follow up and treatment of Positive cases before the disease is progressive. It is useless in the presence of non-representative sampling. A Non Followed positive test is better than no test at all and it’s like money wasted in a river. When new program integration is in the mind of the stakeholders there are pre- planning need assessments needs to be carried, so that at the end, the Cytology department is not point fingered as the causative agent of bottlenecks in terms of service delivery, workloads, turnaround time, quality, and the rest of client satisfaction. 1.4 Introduction There are six (6) Pillars of disease intervention as defined by international cancer prevention guidelines (WHO 2002. These include: 1. Policy, guidelines, rules, regulations, SOP’s, documents, 2. Prevention- education and training- long / short/, in-house and on going -Screening – Pap smear / Visual inspection,( VIA) and Colposcopy( VIAM - HPV Vaccination for cervical cancer. 3. Treatment: conisation, LEITZ, Chemo, radiation – Histopathology intervention 4 care and support – compliance & follow up 5. Impact mitigation 6. monitoring and evaluation: even though monitoring is a continuous process that cut across all interventions, processes, both managerial and technical operation , evaluation of the success and the failure of the program is paramount after 5 year strategic planning , in this case 2008-2012.We recognize that many organizational problems results from systems and processes rather than fromindividuals. We encourage staff members at all levels to work as a team, to draw on their collectiveexperience and skills to analyze systems and processes. We use information to identify the natureand size of each problem. We design and implement activities to improve services. When staff begins 4
to make improvements, they themselves monitor the impact of their changes. If at first the desiredoutcomes of the process are not achieved, then the staff can continue to make improvements untilthese results are achieved. In preparing to introduce Continuous Quality Improvement our managersand Director must create an environment for quality improvement by obtaining the commitment ofleadership of Ministry of Health ( DGHS, Family Health). They should focus on the client’sperspective. Analyze the work process and Motivate all levels of staff to participate in a continuouseffort to improve cytology services to include cervical cancer screening servicesThe essence of leadership is the ability of Directors and High Authorities to motivate groups toachieve certain goals, without the use of any force or coercion. A good leader is someone who isfollowed, rather than someone who obviously leads. Someone with the driving force inside andpeople follow him because he inspires trust, he creates confidence that he knows what he is doing inthat particular job.We believe that what workmen want from their employers beyond anything else is high wages.Management Authorities in the Ministry should recognize and realize the importance of praise,attention, and good communications in getting workers to identify and work toward company goals.The real motivators at work are factors relating to the Cytology job itself, like the opportunity forachievement, recognition and career advancement, refresher courses the chance to exercise creativityand to take on responsibility. We have the philosophy and assumptions that we find cytology worknatural, that we exercise self-control in meeting objectives to which we are committed, that we willnot only accept but actively seek responsibility and be part of decision making. We have the moralfibre and spectacles of morality when it comes to practicing our profession. We believe that wherecytology staff participate in decision making, motivation is enhanced through cytology staff becomingmore involved and committed and feeling that their opinion matter.One of the very successful operational mille of cytology include Team work, Process analyses,Measurement & interpretation of data, Problem solving, Monitoring activities, cytology Staff shouldcontinuously be Trained formally, through seminars or workshops. Cytology staff have Emotionalintelligence: The capacity to foster trust and create an emotionally intelligent workforce whosemembers know themselves and know how to deal respectfully and understandingly with others. Theyhave ability to regulate and manage one’s emotions in a healthy and productive manner forproductivity in our practice for National Growth of the discipline to make the cancer diagnosispopular and well accepted in Lesotho. Cancer is a Problem in Lesotho and there are fully trained toaddress all the interventions.We do not apply the “one cap fits all” thinking when confronting cytology challenges. We utilise thebroad framework depicted below to guide our activities to ensure consistency in application.Diagnostic Gap Analysis Intervention Tracking and Monitoring 5
This is a rigorous process, which looks at what the organisation wants to achieve and then identifybottlenecks throughout the entire value chain. In doing this we look at processes, the skills required todeliver the said goals, and finally whether there are right systems to support these processes. Wetherefore look at all three dimensions of change depending on the extent to which change is requiredfor each individual partner involvement. When any new development needs our service a deep rottedneed assessment and analysis should be conducted and a report generated for future reviews ifbottleneck are reported on the side of the Cytology practice. 6
SECTION 2 : 2.1 Achievements to date will be reported on the following areas: Client satisfaction, inventory management and suppliers, equipment performance , internal and external Q.C , audit outcome implementation of corrective actions and improvement projects implementation and follow up management outcomes. a. client satisfaction Cytopathology plays integral part 1. 2 and 6 of the intervention pillars above. In-order for cytology to function well there has to be management and technical operational communication, communication frequencies and logs, and the Laboratory has both internal clients and external clients. Internal clients are - smear takers, nurses, Doctors, facilities to include Treatment facilities _ Memos were sent to clients when service interruptions occurred (doc# FRM GEN 013) records available. External clients-the Cytology Laboratory does not have direct contact with the patients butthere have been avenues to perform education and training through social mobilisation andcommunity campaigns calculated by a number of health education programs, and trainings andparticipants trained Suppliers: the only supplier we have had interaction is the scientific group, where the new machine was purchased. Machine Installation and staff competency trainings have been carried by this supplier. The introduction of this new machine has resulted in the Reduced TAT- 3wks to 6 working days . This is sessional and there increased TAT is when staff are paced on call as the cytology staff go on call and off duty one after the other( consecutively) refer to the on call duty rota. installation of new equipment changed TAT but moving to the new premises caused interference in 3 months as the piping systems had to be interphased with the machineb. Inventory Management and suppliers Cross cutting situation in all departments. This has been addressed in QAO meetings and TWG meetings, to date. Procedures include the Logistic officer who gets requisition in time when our stock is at the re- order level. Lead time is determined and depends on what commodity is not available at NDSO. NEW Procument cycle is determined by QAOc. equipment performance There was no staining machine earlier work load was alarming with backlogs, and staff were exposed to xylene, alcohol and formaldehyde hazards which are corrosive and carcinogenic and the Government does not provide risk allowance for staff. 7
New machine is in place now Reduced TAT No break downs yet as the machine is newd. internal and external Q.CThere is no funding to run EQA this year 2013, we are still preparing proposal writing for funding asthis is not in the Laboratory Budget. IQC: Done on staining check EQA: Done for the 1st time in Lesotho o Constitute an educational material o See results in 3 slides for General cytology Fine Needle Aspirates and FNA Key: unaccpt= un acceptable Targ= Taget Accept. = acceptable 8
Case studyCases: participation12 FNA- 7ParotidPreparation –2 pap QDClinical: male , 52 years. Parotic swelling ,Cytology:This is a sanguineous and a mucinous back grounded smear with some cells in glandular groups, 3dimensional syncytia, and rosettes configurations are present. There is marked cellularpleomorphism , anisonucleosis, nuclear noses, pulled out tad poled and indentations. Cells exhibitsalt and pepper coarse chromatin granulation - slide 5682 ( red and green colour)5684Cell syncytia, cell pleomorphism, noses, and macro-nucleation seen.Bi- Nucleation , , mitotic figures with promonent nucleoli seen .5658Mixed mesenchymal cells with pulled out cells, some cells are single lying, the size of the single lyinglymphocyte.Diagnosis: Adenoid cystic carcinomaFinal diagnosis: Malignant: 10
e. audit outcome Baseline done – April 2011 = 1 star June 2011 = 2 star -Sept 2011 = 2 star -Final = 2 starf. implementation of corrective actions + improvement projects No validated report of machine Baseline assessment was carried Tools developed as improvement project improvement project resultsg. implementation and follow up management meetings outcomes SOP’s – FRM-GEN-018 evidence of developed corrective actions after meetings Evidence of sectional meetings carried 30th Jan Last meeting Calendars not yet approved for General Staff meetings, TAC 11
SECTION 3. 3.1 2012- 2013 CHALLENGES clients -Internal Clients: poor smear takers – eg Mohale’s hoek and Mafeteng o Delayed slide transportation to central lab – eg after 3 months from date taken o Slide labelling a problem some times o Improvement project to determine the problem revealed that clinicians , leave slide on windows, for drying and then forget sending samples to the lab o Drivers travel with samples , up and down without delivery to the Laboratory. external clients Recall and follow up is poor and not done SOP’s for patients need to be developed DISA ; should demonstrate the recall follow up schedules like it appeared in the vendor demonstration Inventory mamagement :Problems are cross cutting in all sectionsEQA: Some EQA material come on CD-ROM and the Cytology section does not have a Lap Top forEQA implementation Poor performance on FNA results , as a results of poor follow up on training plan for re- fresher courses and recertification process There is no budget for EQA in 2013 12
SECTION 4 :4. Way forward Carry comprehensive survey of clients satisfaction is mandatory Carry comprehensive review of Laboratory Motivation towards staff improvement and satisfaction. Train smear takers on quality smear taking, modalities of follow up and interpretation of results in 2012 and on-going as there is marked staff mobility Purchase of Lap Tops for EQA and on going trainings. The Management should polish both the furniture and the staff: Technology changes fast, and Intensive Refresher courses, re-certification processes and CPD point systems for Cytology staff as prerequisite for professional staff development is needed. This is not done internally but outside the Country. Improve the capacity of Cytology laboratory health personnel as defined in the Policy Improve management systems within the National Health sector, Laboratory Services and Cytology Laboratories – This is a rigorous process, which looks at what the organisation wants to achieve and then identify bottlenecks throughout the entire value chain. In doing this we look at processes, the skills required to deliver the said goals, and finally whether there are right systems to support these processes without imposing workload with coercion. We therefore look at all three dimensions of change depending on the extent to which change is required for each individual partner involvement. When any new development demands our service a deep rotted need assessment and need analysis should be conducted and a report generated for future reviews if bottleneck are reported on the side of the Cytology practice, Things should not be imposed of the section without their total involvement.. Establish a chain of command and career ladder for Cytology because what they do is unique, not every technologist can do in the pool of workforce the Ministry has. Perform Monitoring and evaluation of the National Reproductive Health cancer Guidelines, HPV vaccination services and review of National RH Guidelines by 2012, especially the training needs. It should not be forgotten that the general Management system of cytology services have integration linked to Family Health, Disease control, the Laboratory and CHAL and is managed at the National Level. a coordinator of these service has not been appointed as indicated in the National RH Cancer Guidelines 2008, when will the Laboratory initiate this?, there is no evidence of autonomy in the section , all staff are on the same position irrespective of experience history and performance indicators. This can be linked as a vehicle for decline in performance and can result is staff resignation, soldering on the job and mass resistance. So urgent improvement is advised. M/E of cytology in the cancer reduction process according to the 2008 National RH Guidelines. 13