|
Recommendation |
Actions Taken / Next Steps |
Status |
01 |
As
testing methodology and "best practice" continue to evolve
as a result of improvements in technology and advances in
research, it would not be appropriate to dictate how testing
should be performed. The creation of the policies and
procedures currently in place at Eastern Health was an
important first step towards ensuring that its estrogen and
progesterone hormone receptor testing systems and processes,
and quality assurance systems reflect "best practice."
Eastern Health must identify who is responsible for
continual monitoring of consensus statements issued on and
research in the area of immunohistochemistry and ensuring
appropriate modifications are made to the testing
protocols. |
Eastern Health's immunohistochemistry laboratory has a
committee consisting of three pathologists that has assumed
responsibility for laboratory procedures, protocols and
quality control. Eastern Health has engaged the University
Health Network to, among other things, provide specialist
services in immunohistochemistry.
|
Completed |
02 |
It
is recommended that the Government of Newfoundland and
Labrador create a position of Provincial Director of
Pathology and Laboratory Services for the province. This
position should exist within the Department of Health and
Community Services and be independent of the regional health
authorities. The Department should create a job description
for this position that clearly outlines the duties and
responsibilities, which should include:
i.
assisting the regional health authorities in development of
policies and procedures;
ii.
encouraging a collaborative culture of quality within
laboratory medicine;
iii.
coordinating efforts amongst regional health authorities to
ensure adequate pathology locums are available;
iv.
facilitating the regional health authorities' preparation
for accreditation of laboratories;
v.
coordinating educational opportunities and dissemination of
information amongst pathologists throughout the province;
vi.
coordinating educational opportunities and dissemination of
information amongst laboratory staff throughout the
province, including technologists and pathology assistants;
vii.
promoting a high quality of pathology and laboratory
services throughout the province;
viii. creating a strategic plan for provincial recruitment
and retention of pathologists and laboratory medicine
technologists. |
The position of
Provincial Director of Pathology and Laboratory Medicine has
been created and the position has been advertised. The
provincial director will be located within the Department of
Health and Community Services (the department) and will
report directly to the medical consultant. This position is
also affiliated with Memorial University School of Medicine. |
Substantially
complete |
03 |
In
recognition of the critical importance of "quality," it is
recommended that in each regional health authority there be
a separate quality portfolio. A separate position of
Vice-President Quality must be created to manage this
portfolio. The individual in this position would have a
multi-functional role that includes providing assistance to
all departments in areas of quality assurance and quality
control, and ensuring all policies and procedures relating
to quality are being fully complied with. While risk
management might fit within this portfolio, claims
management should not be included. |
Each Regional Health Authority (RHA) has created a
position of Vice-President (VP) Quality whose main responsibility is
quality.
The VP Quality is responsible at the senior management level
for implementing the Cameron recommendations. Claims
management is not a responsibility of persons occupying the
VP Quality position. |
Completed |
04 |
It is
recommended that the Government of Newfoundland and Labrador
require each regional health authority to obtain a license
in order to operate a laboratory.
It is further recommended that as a condition of licensure,
each regional health authority must participate in a
recognized accreditation program for laboratories. A
national program would raise the standard of practice across
the country. A national accreditation program, therefore, is
the optimum method of accreditation. I recommend that the
Government of Newfoundland and Labrador utilize best efforts
to work with other provinces towards establishing a national
accreditation program. In the interim, it is recommended
that the province require, as a condition of license, that
each regional health authority participate in a recognized
laboratory accreditation program to ensure that the
laboratories within this province operate at the standard
required for accreditation. All regional health authorities
should have support for meeting these standards. Examples of
support required are funding to bring the laboratories up to
accreditation standards and assistance, the preparation of
manuals and policies for practice. It is important to note
here that the external laboratory accreditation program
should be a complement to other external and internal
approaches to proficiency testing and quality assurance. |
The
minister has informed CEOs that all RHAs must participate in
mandatory laboratory accreditation. Quality Management
Program - Laboratory Services (QMP-LS) has been identified as
the preferred vendor to conduct this laboratory
accreditation. QMP-LS offers accreditation services based
upon standards specified by the International Standards
Organization (ISO).
The issue of laboratory licensing will be placed on the
national Health Ministers' agenda for September 2010
meetings. |
Partially complete |
05 |
Reports were prepared by Mr. Williams Parks and Mr. Bryan
Hewlett on review of laboratories at each regional health
authority. It is recommended that each regional health
authority implement the recommendations contained in the
report related to that health authority. It is further
recommended that each regional health authority examine the
reports relating to other health authorities and implement
any recommendations also relevant to their laboratories. For
example, implementing a practice of further separating
cassettes in the tissue processor as done at the Charles S.
Curtis Memorial Hospital may be appropriate for laboratories
at other regional health authorities. |
RHAs have made significant progress in implementing
Hewlett-Parks recommendations.
Western Health — 12 of 14 Hewlett-Parks recommendations from
the October 2, 2008 review are in place. The two remaining
recommendations are in progress and refer to continuing
professional development and the hiring of a Technologist
III position who would be assigned responsibility for
processing quality control information.
Eastern Health — Seven of 11 recommendations are in place,
two recommendations are in progress, another is implemented
using another process, and one is outstanding. The
outstanding recommendation involves slides and blocks being
brought together for comparison after staining.
Labrador-Grenfell Health - 20 of 24 Hewlett-Parks
recommendations are in place. Four recommendations are in
progress.
Central Health — 16 of 18 Hewlett-Parks recommendations from
the October 3, 2008 visit to James Paton Memorial Regional
Health Centre, Gander, have been completely implemented at
James Paton and Central Newfoundland Regional Health Centres.
The remaining two recommendations are in progress.
RHAs have shared and reviewed each others' reports and are
in the process of determining which recommendations targeted
for specific RHAs might also be applicable to them. |
Substantially complete |
06 |
It is
recommended that each regional health authority establish
morbidity and mortality (quality assurance) rounds for
pathology; Eastern Health should also establish such rounds
for medical oncology.
Both Dr. McCarthy and Dr. Laing, in their testimony before
the Commission, discussed the importance of these rounds to
quality assurance. All pathologists and oncologists should
be required to participate in such rounds as a condition of
continued employment with the regional health authority;
accommodations need to be made to allow participation by
pathologists and oncologists who work in areas that would
prevent them from physically attending. These accommodations
could include the use of teleconference or videoconference
technology. Best practices for these rounds should be
developed as soon as is practicable.
|
Eastern Health pathologists now participate in patient
specific (tumor board) rounds, grand rounds (educational —
around specific topics) and morbidity and mortality rounds
with oncologists. The oncology program at Eastern Health is
developing provincial multidisciplinary morbidity and
mortality rounds with pathologists and oncologists.
While historically morbidity and mortality rounds have
worked under an informal structure, a template for such
rounds, developed by Eastern Health has been shared with
each RHA. RHAs are now in the process of adapting this tool
for implementation and pathologists will be active
participants in these rounds.
Many of the rounds mentioned above are, by their nature,
multidisciplinary in their format. The department is about
to engage an individual to research, recommend, implement,
and evaluate best practice in multidisciplinary rounds for
Newfoundland and Labrador which include oncology rounds. |
Partially complete |
07
|
Pathologists
and oncologists should be required to participate in
multidisciplinary rounds.
The regional health authority should be responsible for
ensuring the development of best practices for these rounds.
Quality assurance and quality control must be considered a
mandatory part of the job of all clinicians. |
08 |
Time required
for participation in rounds should be considered when
determining the number of pathologists and oncologists
required for each institution so that physicians do not have
to choose between day-to-day tasks and participation in the
quality assurance process. This is consistent with the
report of Dr. Maung to the Government of Newfoundland and
Labrador in 2007. |
The appropriate number of oncologists and pathologists in
the province has been allocated as recommended in Dr.
Raymond Maung's report of 2007. Dr. Maung is an expert in
the field of pathology workload assessment. The time
required for quality assurance, research, continuing medical
education, teaching and administration has been factored
into the RHA allocation for pathologists and oncologists. |
Completed |
09 |
It
is highly desirable to collect all data required to maintain
laboratory metrics for estrogen receptor and progesterone
receptor test results. It is therefore recommended that each
regional health authority designate a staff person who is
responsible for tracking ER and PR metrics within the
regional health authority. It is recommended that Eastern
Health track metrics not only for its own patients, but also
for results of all tests completed at the IHC laboratory.
These numbers should be compiled, at a minimum, on an annual
basis. All regional health authorities should provide
reports containing this data to the Department of Health and
Community Services. This data would be a valuable tool for
detecting potential problems, although it is important to
point out that, as Dr. Mullen told the Commission, waiting
for a deviation from an expected percentage would not be the
most prudent or expeditious way to detect problems.
Investigations should still be triggered based on individual
cases that deviate from the norm, since to misdiagnose or
misinterpret one test result affects patient care
substantially. |
Each RHA has designated a staff person for tracking ER/PR
metrics. When Eastern Health does resume ER/PR testing it
will be tracking ER/PR metrics for the province. The review
of daily quality control checks will enable identification
of cases that deviate from the norm and clinicians are to
discuss such deviations with laboratory personnel. The
Minister of Heath and Community Services has notified RHAs
that ER/PR metric reports are to be submitted to the
department semi-annually. |
Completed |
|
10 |
It is
recommended that information collected by regional health
authorities relating to quality control and quality
assurance within their laboratories be used appropriately to
take corrective actions to prevent occurrences from
happening. This information should be kept in electronic
format for more effective usage and analysis of the
information. |
Quality management is a critical issue for RHAs and the
department and quality control / assurance are essential elements of a quality
management system.; Budget 2009-10 committed $1 million for laboratory
accreditation and $1.3 million for additional laboratory
staff. RHAs continue their work to ensure that information
collected relating to quality control / assurance within
their laboratories is used appropriately to take corrective
actions and therefore prevent occurrences.
Central Health has initiated phase one of QMS development
and has hired two quality managers and an IT specialist for
laboratory services.
Western Health has implemented a protocol for corrective
action from a quality control aspect and has hired a quality
assurance manager and a clinical IT specialist.
Eastern Health has created a new Quality Management Division
in Laboratory Medicine. Eight quality coordinators are
assigned to this department. Eastern Health is developing
and implementing its laboratory QMS in compliance with ISO
15189 for medical laboratories.
Labrador-Grenfell Health has quality management policies in
place and has created two laboratory quality assurance
positions and an IT laboratory administrative position.
The department will continue to work with RHAs to ensure
greater standardization of their quality management
systems.
With the exception of Labrador-Grenfell Health, much of the
RHA quality control information is already captured in
electronic format. All RHAs, using the Meditech Laboratory
Information System, are moving toward electronic capture for
the majority of quality control information. |
Partially complete |
|
11 |
It is
recommended that all regional health authorities utilize
proficiency testing within their laboratories.
The quality and safety framework within each regional health
authority should include a regular schedule of internal and
external audits, and these audits must cover all aspects of
work being performed in the pathology laboratories. Internal
reviews, such as the exchanges that have been conducted
between Grand Falls and Gander, and Carbonear and
Clarenville, should be encouraged and continued. Other
regions should consider setting up similar exchanges. |
All RHAs utilize proficiency testing within their
laboratories. Currently, RHAs engage in internal and
external auditing, to varying degrees. When the Provincial
Director of Pathology and Laboratory Medicine is in place,
the director will be tasked with ensuring there is a
standardized program of internal and external audits.
Target completion date for standardization is April 2011. |
Substantially completed |
|
12
|
I note that
Eastern Health is in the process of implementing an
electronic occurrence reporting system. All other regional
health authorities should implement a similar system, with
co-operation and coordination among all four regional health
authorities to ensure the system is utilized to its full
potential and that information gained within each authority
can benefit all health authorities and prevent the repeating
of similar adverse events. |
In Budget 2009, the Provincial Government committed $3
million to expand Eastern Health's Clinical Safety Reporting
System to all RHAs. NLCHI is responsible for this expansion
and has released a request for proposals to implement this
project. Target completion date for all RHAs is March 2012. |
Partially complete |
|
13 |
Eastern Health, as mentioned above, has created standard
operating policies and procedures for their laboratory. All
other regional health authorities should ensure that
standard laboratory operating procedures are in place, That
staff are made aware of these procedures, and that a process
is in place to ensure compliance. These policies should also
contain provisions to ensure they are regularly reviewed and
updated. |
RHAs are ensuring that all standard operating procedures are
in place and documented, that personnel are aware of these procedures and that a process is in place to
ensure compliance. Eastern Health alone reports over 700
standard operating procedures for their laboratories. This
work will be completed by March 2011. |
Partially complete |
|
14 |
It is
recommended that there be an assessment to identify upgrades
required to the laboratory premises and laboratory equipment
within the Central, Western, and Labrador-Grenfell Regional
Health Authorities. Resources needed to complete required
expansion or upgrades to prepare these laboratories for the
accreditation processes should be provided. |
As RHAs go through the ISO laboratory accreditation process,
a formal assessment to identify upgrades required to
laboratory premises and equipment will be conducted. This
assessment will be additional to the department's annual RHA
needs assessment in terms of facilities and equipment. In
2009-10 the Provincial Government invested $4.7 million to
upgrade laboratory equipment and facilities. Additional resources
needed to complete required expansions or upgrades indicated
in the laboratory accreditation process will be allocated as
necessary.
|
Partially complete |
|
15
|
At
the time of the review of Mr. Parks and Mr. Hewlett, a
noticeable disconnect existed between individual work areas
within the histology laboratory at Eastern Health and the
management goals. Dr. Banerjee also noted in his initial
report that "superior outcomes could be achieved by ensuring
better linkages between technical, managerial and medical
leadership." Accountability has to be clear; the reporting
structure within the Laboratory Medicine Program of Eastern
Health must reflect the requirement of interaction between
technologists and physicians to ensure best possible quality
assurance outcomes. I recommend leadership training for
management within the pathology division of the Laboratory
Medicine Program. |
Since the release of the Cameron Report, the reporting
structure at Eastern Health has changed significantly. The
Chief of Laboratory Medicine now has the overall authority
and accountability for the Laboratory Medicine Program. This
is reflected in Eastern Health's revised organizational
chart. The
Chief of Laboratory Medicine and other management staff will
continue to participate in leadership training. |
Completed |
|
16 |
As
noted in the report of Mr. Hewlett and Mr. Parks, staff in
the laboratory is in constant flux, which is
counterproductive to a motivated, highly skilled, and
productive technologist work force. While Eastern Health has
dedicated three technologists to the IHC service, a
succession plan should be implemented to minimize future
attrition problems. The Canadian Society for Medical
Laboratory Science states that a shortage of medical
laboratory technologists will occur as large numbers of
medical laboratory technologists retire over the next five
to ten years. This shortage must be addressed so that
patient waiting times, and therefore timely access to
appropriate treatment, are not adversely affected. The
Department of Health and Community Services should carry out
an analysis of requirements for medical laboratory
technologists within the province for the foreseeable future
and take steps to address any potential shortage. Addressing
any potential shortage of medical laboratory technologists
must not be accomplished by lowering the standards for
admission into the training program. |
A Laboratory Human Resources Planning Committee has been formed
at Eastern Health, chaired by the Director of Laboratory
Medicine. This committee comprises staff from the Human
Resources Program and Policy Development Department, as well
as laboratory technologists from city hospitals and
outside-city laboratories at the regional level. A
department-led Cameron Provincial Working Group is preparing
a medical laboratory technologist workforce model, with a
draft report expected by May 2010. |
Partially complete |
|
17 |
With advances
in technology and knowledge in the area of
immunohistochemistry, highly skilled laboratory staff will
be required to implement successfully new protocols and
procedures. Eastern Health must develop, maintain, and
update as appropriate all job descriptions for both
technical and medical staff working in the IHC laboratory. |
Eastern Health is updating job descriptions for all
laboratory positions including Immunohistochemistry
laboratory positions. This work will be completed by
September 2010. |
Substantially complete |
|
18 |
Eastern Health should develop formal in-house training
programs for new immunohistochemistry technologists. Until
these training programs are developed and implemented,
Eastern Health should retain outside expertise to attend at
its IHC laboratory to train the new staff. As a less
desirable alternative, new staff could be sent for training
to a laboratory that already has an acceptable training
program in place. It is helpful to refer to the testimony of
Ms. Maria Tracey on orientation and training for operating
room nurses. The strict approach developed and followed for
the nursing peri-operative program should be applied to
laboratory technology staff, as these positions are also
extremely important to safe and accurate patient care.
Reference should also be made to the testimony of Ms.
Patricia Wegrynowski, Mr. William Parks, and Mr. Bryan
Hewlett relating to training required for laboratory staff
at their respective institutions. |
Eastern Health continues to work to develop standardized
training and educational programs throughout its
laboratories. Eastern Health is in the process of
developing its own in-house training program for
immunohistochemistry technologists. |
Substantially complete |
|
19 |
To
ensure continuing quality within pathology laboratories, it
is recommended that histology and IHC laboratory
technologists be required to demonstrate their competency,
at a minimum, on an annual basis. All regional health
authorities must conduct annual performance evaluations of
histology and IHC technical staff and managers. |
RHAs have policies that require either annual or bi-annual
performance evaluations. RHAs that have not already done so
will amend policies as necessary, to ensure performance
evaluations of
histology and IHC technical staff and managers
occur annually. These policy amendments will be competed by
May 30, 2010. Some RHAs have already completed this round of
performance evaluations; the remaining RHAs will complete
evaluations by August 2010. |
Substantially complete |
|
20 |
All
immunohistochemistry and histology laboratory technologists
should be required to complete mandatory continuing
education each year. Continuing education is vital in any
area that continues to have new developments, particularly
laboratory medicine. Regional health authorities should work
cooperatively on this to ensure resources are maximized.
Technologists should also be encouraged to complete online
courses. Regional health authorities should support this
effort by providing staff with the time required to complete
the courses and the funding to pay for them. |
The Health Professions Act (umbrella legislation)
will mandate continuing education for all professions
governed under it. This legislation will be ready for the
spring 2010 sitting of the House of Assembly. Currently,
RHAs support and actively encourage continuing education
programs (for example, Canadian Society for Medical Laboratory Science education
modules) and provide opportunities for personnel to attend external
professional development sessions. |
Substantially complete |
|
21
|
The Laboratory Medicine Program at Eastern Health in setting its
annual goals and objectives should place a greater emphasis
on investment in human resources. This would assist in
creating an environment that attracts and maintains highly
qualified staff, and encourage their ongoing professional
growth. In their review of Eastern Health laboratories, Mr.
Parks and Mr. Hewlett noted that implementing new
technologies requires not only purchasing new equipment, but
also a "strong core group of experienced technologists with
intimate knowledge and deep understanding of the current
technology and willingness to learn and apply the new
technology. The application of any new technology without
this experience, knowledge and understanding can have dire
consequences." |
The laboratory operational plan includes a goal and
objectives to enable achievement of this recommendation:
GOAL
By March 2011 Laboratory Medicine shall have a workforce
plan that addresses:
—
Recruitment and retention
—
Succession, including for low critical mass departments such as
Immunohistochemistry and others
—
Recommendations for effective utilization of staff
—
Continuing education plan
—
Performance management and recognition
—
Uniform qualifications
OBJECTIVES
—
Evaluate current staffing levels and future workforce projections
—
Establish a laboratory workforce planning advisory group in
collaboration with Human Resources Department
—
Complete annual performance appraisals
—
Develop and complete position descriptions for all
classifications as well as specialty positions
—
Put processes in place to establish a plan for continuing
education to ensure qualifications and required competencies
are maintained
To date, the following have been undertaken:
—
Establishment of a laboratory workforce advisory group consisting
of human resources consultants, laboratory managers, and
technologists
—
A review of staff levels and workload was completed at the end of
the last budget cycle to enable identification of resource
needs for current workload
Qualifications reviews are on-going with the Human Resources
consultants. |
Partially complete |
|
22 |
It is
recommended that the legislation currently being developed
for licensing and regulation of medical laboratory
technologists be completed as soon as is practicable. |
Umbrella legislation will be introduced in the spring 2010
sitting of the House of Assembly. Licensing of medical
laboratory technologists will occur following the passing of
the legislation. |
Substantially
complete |
|
23 |
While the
province has substantially increased the benefit package
available to pathologists in this province, there must be a
plan developed to ensure the sustainability of this
professional group. With respect to recruitment, the
Department of Health and Community Services should develop a
contingency plan for the establishment of pathology services
in the event that an adequate number of qualified
pathologists cannot be recruited and retained in all
provincial hospital laboratories. Particular emphasis should
be given to recruitment efforts in rural areas to allow
"respite" for pathologists who work alone in institutions
and have no colleague to relieve them. To this end, the
Department of Health and Community Services should develop
and implement a system to ensure adequate locums are
available for pathologists. The Department of Health and
Community Services should also implement a system to assess
pathology manpower requirements on an ongoing basis. The
regional health authorities must also continue to ensure
recruitment and retention of pathologists is given high
priority. |
The province has a strategy to recruit and retain
physicians, including pathologists. This year, as part of
the strategy, the department has funded recruitment officers
for each RHA; these officers will be appropriately trained.
The process to assess human resource requirements for
pathology is included in a report completed by Dr. Raymond
Maung. The current allocation of pathologists to RHAs was
based upon Dr. Maung's assessment using a workload
measurement tool. The tool will guide the department in the
ongoing assessment of pathologist requirements for the
province. The department is examining best practices
nationally and internationally with a view to developing a
provincial locum registry for physicians. Target completion
date for the provincial locum registry is May 2010.
|
Completed |
|
24 |
The Department
of Health and Community Services and the regional health
authorities should work together to explore alternative
means of providing pathology services within the province
and assistance to pathologists in their practice. It is
recommended that a program be implemented to provide
pathologists who work alone with a means for receiving
feedback, advice, and interaction from colleagues. The
Department of Health and Community Services should also
ensure that adequate resources are available to fund
technical resources such as telemedicine technology,
particularly for pathologists who work alone, as well as new
technology in the field of pathology digital imaging and
computer transmission. |
In 2009, Canada Health Infoway officially approved a
proposal submitted by a Tri-Provincial partnership including
Newfoundland and Labrador, Manitoba, and Ontario for a
multi-jurisdictional telepathology network planning
project. The intention of this project is to replicate the
Northern Ontario telepathology project whereby provincial
hubs are created in Newfoundland and Labrador and Manitoba.
Once fully operational, all three participating
jurisdictions will benefit from the ability to remotely
engage pathologists to support local workload management
issues and to access sub-specialty pathology services. This
will result in earlier completion of expert pathology review
and diagnosis, and expediting treatment decisions including
timely access to surgery where appropriate. At present solo
pathologists in Newfoundland and Labrador have linkages
developed with colleagues internal and/or external to the
province so that feedback, second opinions, and further
advice can be provided. The department will make continued
funding available as necessary to support this
recommendation. |
Substantially complete |
|
25 |
The Department
of Health and Community Services should investigate and
study the potential for the expansion of services that could
be provided by pathology assistants to laboratories in the
province. |
The department has determined there is a role for pathology
assistants within the province; however, some RHAs report
limited availability of trained people to fill these
positions. Furthermore, contact was made with the Canadian
Society for Medical Laboratory Science (CSMLS) who indicated
it would not be developing IHC and pathology assistant
training programs. Discussions are on-going with Eastern
Heath to examine the possibility of developing a provincial
training program for pathology assistants. |
Completed |
|
26 |
Pathologists should have a positive obligation to identify
and inform their superiors when they have inadequate
experience or any limitation in their ability or expertise
with respect to performing a particular test or in assessing
any particular case. |
Pathologists have an ethical obligation as part of licensure
to identify professional limitations and report the same to
their superiors. |
Completed |
|
27 |
Continuing
medical education for pathologists and oncologists must be
mandatory and funded.
Each regional health authority should develop a written
protocol for continuing education for pathologists and
oncologists in accordance with the requirements of the
region. Each regional health authority has the
responsibility to ensure the protocol is followed, and that
adequate protected time and resources for these physicians
is provided to allow them to participate.
|
The department provides annual continuing medical education
funding to pathologists and oncologists. The minister has
written RHA CEOs directing them
to
make continuing education for pathologists and oncologists
mandatory. RHAs will complete
written protocols for continuing education for pathologists
and oncologists by June 30, 2010.
The College of Physicians and Surgeons of Newfoundland and
Labrador (CPSNL) is developing a revalidation process
whereby every physician will be required, on an annual
basis, to show evidence to CPSNL of continuing medical
education. Physicians certified by the Royal College of
Physicians and Surgeons of Canada or the Canadian College of
Family Physicians must complete mandatory continuing medical
education in order to maintain certification.
|
Substantially complete |
|
28 |
It is
recommended that the appropriate person within each regional
health authority complete an annual performance review of
the work of each pathologist and oncologist. The regional
health authority is responsible for ensuring these reviews
are completed. |
The majority of these annual performance reviews are
complete. Two RHAs will have this year�s performance
reviews of the
work of each pathologist and oncologist completed by March
31, 2010. The other two RHAs will have this work completed
by August 2010. |
Substantially complete |
|
29 |
It is
recommended that the Royal College of Physicians and
Surgeons of Canada consider expanding opportunities for
sub-specialization within pathology. |
The Director of Education at the Royal College of Physicians
and Surgeons Canada (RCPSC) has been contacted. Currently
there are no plans for further sub-specialization in
pathology. The RCPSC does have in place a diploma program so
that additional skills can be developed in a particular
field. This allows local expertise to be developed under
national standards while the overall function of the
pathologist as a generalist continues.
In addition, the minister has written the RCPSC to request
that they consider expanding opportunities for
sub-specialization within pathology. |
Completed |
|
30. |
Given the
shortage of pathologists, faculties of Medicine are
encouraged to promote interest in pathology as a specialty
by exposing students to pathology in the early years of
their program. Faculties of Medicine are also encouraged to
expand their curriculum to ensure all medical students are
educated as to the important, underlying role of pathology
in the practice of medicine. |
The Acting Dean of Memorial University's Faculty of Medicine
reports that at Memorial University all specialties are
promoted in the Medical School. In addition, the acting dean
confirms the new curriculum to be introduced in 2012 will be
much more clinically relevant for pathology beginning in the
first month of medical school. The Undergraduate Office of
the Medical School is exploring the possibility of offering
a four to six month longitudinal experience in pathology
during the final year of medical school. |
Completed |
|
31 |
Each regional
health authority must develop and maintain a crisis
management plan. Elements of a crisis management plan must
include:
i. a
clear articulation of the roles of those managing the
crisis;
ii.
information management and record keeping;
iii.
the role of the Board of Trustees;
iv.
identification of special skills required to manage the
crisis;
v.
provision for notification of the Minister responsible
under the Regional Health Authorities Act;
vi.
a plan for communications, which would include with whom one
should communicate, when communications should occur, and
the method used to communicate;
vii.
a conflict of interest policy. |
Three RHAs have finalized draft crisis management plans that
include the "core elements" as specified in the Cameron
Report. A fourth RHA's crisis management plan is complete
with the exception of a crisis communications component. All
four RHA crisis management plans will be finalized by April
2010. |
Substantially complete |
|
32 |
Regional health
authorities should develop a protocol for management of
multi-regional crises. |
The department will be engaging a facilitator to meet with
RHAs once their individual crisis management plans have been
finalized (April 2010). The facilitator will work with RHAs
to develop a multi-regional protocol, consistent with RHAs'
individual crisis management plans. Target completion date
is June 2010. |
Partially Complete |
|
33 |
It is
recommended that the Government of Newfoundland and Labrador
consider whether section 8.1 of the Evidence Act
remains relevant. |
Recommendations 33, 34 and 35 are under active consideration
and because of their complexity and the level of public
interest will be placed on the agenda for the national
meeting of health ministers in September 2010.
The department will explore the possibility of retaining an
expert in the area to review these issues in further detail.
|
Partially complete |
|
34 |
It is
recommended that any conflict between section 8.1 of the
Evidence Act and section 12 of the Public Inquiries
Act, 2006 be resolved in favour of permitting
Commissions of Inquiry to have access to peer review and
quality assurance reports. |
|
35 |
It is further
recommended that legislation be enacted to specify that
adverse event disclosure to patients include an explanation
of why the adverse event occurred and what is being done to
ensure that a similar event does not occur in the future.
Disclosure should also involve providing the patient with a
copy of any peer review or quality assurance report
respecting the adverse event. As explained in this Report,
the names of the individuals who participated in the peer
review or quality assurance may be removed prior to
disclosure. I recommend that these rights be entrenched in
legislation and that they be given priority over any
prohibition contained in section 8.1 of the Evidence Act. |
|
36 |
It is
recommended that the Government of Newfoundland and Labrador
adopt apology legislation. While in many cases professionals
do not need the protection of legislation to allow them to
apologize, many experts have recognized the importance of
apologies to both the care provider and the patient. |
The Apology Act was passed in the spring 2009 sitting
of the House of Assembly. |
Completed |
|
37 |
The Department
of Health and Community Services should conduct a
province-wide assessment of the information management needs
of the regional health authorities. The communication
problems that became evident during the ER/PR issue
demonstrate why it is essential that this be done on a
province-wide basis. Following this assessment of
information management needs, any system chosen for data
management should be capable of such things as:
i.
ensuring that the results and reports of all diagnostic and
treatment services referred by a physician to a regional
health authority laboratory are transmitted to the treating
physician in a timely manner;
ii.
creating reminders within the laboratory when requested work
has not been completed on a timely basis;
iii.
tracking reports back to the physician who requisitioned
them and confirming that reports are received and opened. If
reports are not opened within a set period of time, the
system should flag the report and send it back to the
originating laboratory for follow-up;
iv.
creating a reminder, after a certain period of time passes,
that a report has not been returned when a consult was sent
to an external institution;
v.
communicating amongst regional health authorities. |
This initiative is being combined with an already existing
e-health strategic planning process. At the request of the
Cameron Provincial Working Group responsible for actioning
this recommendation, NLCHI is to "prepare a high level
compilation of the existing information systems, identify
those that are standardized or capable of presently sharing
information between and among RHAs and between RHAs and
physician offices. Where deficits exist, NLCHI will identify
what needs to be done to correct omissions." A high level
approach for the revised planning process has been prepared
and detailed planning continues. To engage the required
range of stakeholders as effectively as possible and deliver
results sooner, a phased approach is being utilized.
A consultant
team has been engaged for the first phase of the planning
and assessment and the process has begun. |
Partially complete |
|
38 |
The Cancer Care
Program must develop and implement policies and procedures
to ensure treating physicians receive all information
concerning their patients in order to ensure timely and safe
patient care. |
The
Cancer Care Program, Eastern Health, is in the process of
purchasing a new oncology patient information system. A
request for proposals is being completed in which one of the
specific requirements outlined includes capacity of
interface with the Meditech system. Once the new system is
in place, new policies and processes will be developed and
implemented. |
Partially complete |
|
39 |
A
province-wide electronic medical record system must be
developed and implemented, including support for all regions
and positions to have appropriate access to the system.
|
This
is a complicated piece of work that will take years to
complete. The development of an
Electronic Health Record (EHR) has been underway for a
number of years. The following three components are
complete: client registry, provider registry and the Picture
Archiving and Communications System (PACS) for digital
images. The Pharmacy Network went live (November 2009) and
further rollout is ongoing. This system will be rolled out
across the province through fiscal year 2010-11. In March
2009, the Provincial Government announced approval of the
iEHR / labs project which will provide the lab module, along
with improved information sharing between all EHR components. The
Lab/iEHR project is currently at the planning and request for proposal (RFP)
development stage. Budget 2009 also approved funding
for development of a provincial vision/plan for the
consolidation of patient information systems (Meditech)
within regional health authorities. This planning effort has
started.
The above noted initiatives are being led by NLCHI. Canada
Health Infoway has significantly cost-shared
the capital
costs of several
completed and ongoing projects (PACS, Pharmacy Network, iEHR/labs,
provider registry). |
Partially complete |
|
40 |
When one
regional health authority is performing work referred from
another regional health authority, there must be an
obligation to share any information relevant to that work.
The Provincial Director for Pathology and Laboratory
Medicine should coordinate collaboration amongst
laboratories to enhance overall quality of service. |
Under the circle of care model, all RHAs agree that sharing
of information with the appropriate health care provider
must occur, regardless of which health authority performed
the work. While systems are in place for sharing information
across RHAs, the Integrated Electronic Health Record system
will allow all of the functionality required.
The position description for the
Provincial
Director of Pathology and Laboratory Medicine includes
coordination and collaboration amongst laboratories as one
of the director's key responsibilities. |
Partially complete |
|
41 |
Each regional
health authority is responsible for the maintenance of a
record-keeping system which enables responsible physicians
to easily access and search all information required for
safe and timely patient care. As valuable as the Cancer
Registry is for the functions for which it was established,
health authorities cannot abrogate responsibility for
information management by virtue of the fact that the Cancer
Registry exists.
|
The Provincial Records Management Committee continues to
support provincial consistency and ongoing improvement with
records management. The RHAs, NLCHI and the department are
in the process of developing an Integrated Electronic Health
Record System. This will provide a province-wide,
patient-centric view of lab results, medical images, and
related reports, drug information, admissions history,
various medical reports and other elements yet to be
identified. The planned Electronic Medical Record, as a
component of the Electronic Health Record System, will have
enhanced search functionality. This will enable responsible
physicians to
easily access
and search all information required for safe and timely
patient care. |
Partially complete |
|
42 |
I
agree with the review of positive cases currently being
undertaken by Eastern Health where re-test results could
potentially change a patient's original decision relating to
the use of anti-hormonal therapy. A similar review should be
undertaken in each of the other regional health authorities. |
Oncologists,
external to the province, have been contacted to review this
recommendation and provide an opinion as to the value of its
actioning. Terms of reference have been provided to the
oncologists. The department is currently receiving opinions
and once all reports are available it will make a final
determination around recommendation 42. |
Partially
complete |
|
43 |
It is
recommended that the Department of Health and Community
Services engage consultants external to the regional health
authorities to assist with the investigation and decision as
to what action, if any, is required for the remaining
patients who originally had ER positive test results and, to
date, have not been re-tested. This analysis should be
undertaken with a view both to patient care and to obtaining
as much information as possible about the circumstances
which gave rise to the ER/PR problem. The decision as to
whether further testing is required rests with the
Department of Health and Community Services upon receipt of
the consultant's report. |
Oncologists, external to the province, have been contacted
to review this recommendation and provide an opinion as to
the value of its actioning. Terms of reference have been
provided to the oncologists. The department is currently
receiving opinions and once all reports are available it
will make a final determination around recommendation 43.
|
Partially
complete |
|
44 |
It is
recommended that the regional health authorities identify
all patients who have already been re-tested and whose
hormone receptor status changed from "positive" to
"negative" on re-test, and that an analysis be conducted to
ensure that each such individual case has been reviewed to
determine whether patients were appropriately treated and
have been advised of their changed hormone receptor status. |
There are 11 patients in this cohort. An analysis of each
case has been conducted and has revealed that all patients
were appropriately treated. Seven of the 11 patients have
been appropriately notified of their re-tested hormone
receptor status. Two of these 11 were deceased prior to
re-testing and as such their next-of-kin were appropriately
notified. One patient under the jurisdiction of Central
Health and one under the jurisdiction of Eastern Health were
also deceased prior to re-testing and the next-of-kin of
these patients are being contacted as part of the
next-of-kin follow-up related to recommendation 48. |
Completed |
|
45 |
Given the ambiguity surrounding the contact of the patients
from Saint-Pierre and Miquelon, it is recommended that
further investigation be undertaken by Eastern Health to
ensure that all patients have been contacted. |
The final listing of patients identified to be from St.
Pierre et Miquelon is complete. All involved patients (9)
and/or their next-of-kin have been contacted regarding the
initial and re-test ER/PR results. The administration of St.
Pierre et Miquelon acknowledges that all patients have been
appropriately contacted. |
Completed |
|
46 |
It is
recommended that an audit be conducted of the work of the
pathologists who were identified through the ER/PR
re-testing process as having interpreted background staining
incorrectly as nuclear staining. Dr. Dabbs and Dr.
Torlakovic recommended that an audit occur in such
circumstances. |
Eastern Health reports that it was informed by the Cameron
commission staff that the work referenced in this
recommendation relates only to pathologists' ER/PR testing.
Before any decision is made regarding re-starting ER/PR
testing at Eastern Health, external expert opinions will be
obtained pertaining to the appropriate policies, procedures
and audits. |
Partially complete |
|
47 |
Only specimens
from patients with primary breast cancer were candidates for
the re-testing process commenced in 2005. There were
non-primary breast cancer patients who had ER/PR testing
performed between 1997 and 2005 and therefore did not have
their specimens re-tested. It is recommended that a review
be undertaken by an external expert to determine what the
ER/PR test was utilized for in those cases and whether, in
the best interest of these patients, re-testing of their
specimens is warranted. If the expert recommends re-testing
of those specimens, the regional health authority
responsible for each patient must arrange for the re-testing
at the earliest possible time. |
Non-primary breast cancer refers to
cases where the origin of the cancer is not the breast. The
specific circumstance where the ER/PR test is used is for
patients presenting with metastatic cancer and the source of
the primary cannot be found. In these situations the patient
would undergo a multitude of diagnostic testing including
ER/PR testing in an attempt to determine the etiology of
their metastatic disease. Correspondence is ongoing with Dr.
Nevin Murray, medical oncologist with the British Columbia
Cancer Agency, and the department is seeking further
clarificationon re-testing of specimens. This group of
patients would be very small in number. |
Substantially completed |
|
48 |
It
is recommended that all reasonable efforts be made to
identify and contact next of kin of the deceased patients
whose specimens were re-tested as part of the ER/PR review.
The regional health authority responsible for each of these
patients should send letters to the next of kin advising
that re-testing results are available and providing
contact information to obtain the results should they wish
to do so. |
The RHAs and the department collaborated closely to develop
a work plan around this recommendation. Letters to
next-of-kin have been released indicating that re-test
results for their family member are available upon request.
|
Completednt> |
|
49 |
It is
recommended that the Department of Health and Community
Services engage the Newfoundland and Labrador Centre for
Health Information to undertake further investigation as to
whether any other use could or should be made of the data
that was retrieved by the Commission from the DAKO
Autostainer. As well, an analysis should be undertaken to
determine whether the data can provide any useful
information on the cause of the changed results, such as
whether there is any correlation between changed test
results and particular runs or particular dates. |
In March 2009, the Newfoundland and Labrador Centre for
Health Information (NCHLI) contracted Patricia Wegrynowski,
Mount Sinai Hospital, to extract the data from the DAKO
system and provide NLCHI with a usable database for
analysis. Ms. Wegrynowski reported that only 230 out of an
expected 3,000 ER/PR records were found on the DAKO files
provided to the NLCHI by the Commission of Inquiry. NLCHI
determined that further analysis of 230 files recovered
would not provide any added value as the files contained
very little information. NLCHI considered the gold standard
was to conduct a review of paper charts and the RHAs'
hospital information systems. |
Completed |
|
50 |
It is
recommended that data from the ER/PR re-testing review,
including any subsequent reviews carried out pursuant to
these recommendations, be collected and analyzed to obtain
all useful information from this event. As there is a dearth
of studies on this issue, review and analysis of available
data presents an opportunity for research to be carried out.
For example, patients who were placed on anti-hormonal
treatment following changes in their ER/PR results should be
followed and data collected to determine the efficacy of
treatment initiated at various times post-diagnosis. |
The department has formally accepted a proposal to partner
with Eastern Health and the Dr. H. Bliss Murphy Cancer Care
Foundation to create an ER/PR research fund. Details on this
fund will be announced shortly by the three partners.
|
Substantially complete |
|
51 |
All regional
health authorities should have a policy to deal with
disclosure of adverse events. Disclosure relating to adverse
events should include:
i.
the facts;
ii.
the actual or potential impact of the event on the patient;
iii.
an expression of sympathy or regret;
iv.
an overview of the process that will follow;
v.
an explanation of why the event occurred;
vi.
what is being done to ensure that a similar event does not
occur in the future;
vii.
whether a review has been conducted: if so, the patient is
to be provided with a copy of any reports emanating from the
review, if requested;
viii. an offer of future meetings;
ix.
time for questions;
x.
offers of support. |
All RHAs have a policy in place to deal with disclosure of
adverse events which includes the elements outlined in the
Cameron Report. |
Completed |
|
52 |
The
skills for communicating with patients about adverse events
can be learned. Physicians should be trained in disclosure
of adverse events. The training of physicians should include
not only patient disclosure, but also patient safety and
quality assurance practices. This training should be part of
continuing medical education. |
Phase one of training, which included physicians, was
conducted by the Institute Healthcare Communications in St.
John's in October 2009. Phase two training will be
conducted at the RHA level in the spring 2010. At the end
of phase two, staff within RHAs will be certified to conduct
training sessions. Funding is being provided by the
department for phases one and two training. |
Substantially Complete |
|
53 |
It is also
important that staff involved in disclosure of adverse
events to patients have the skill and knowledge to do so.
The regional health authorities should identify the
appropriate persons to conduct disclosure, what support
these individuals need, how best to educate them as to the
particulars of occurrences, what they should convey to the
patients, and the health authority's disclosure policy. |
RHAs have identified appropriate persons to conduct
disclosure. Training sessions referred to in recommendation
52 are designed to educate staff as to the particulars of
occurrences, what they need to convey to patients, and
health authority disclosure policies. RHA disclosure
policies also address what support these individuals need. |
Completed |
|
54 |
It
is recommended that for ethics consultations occurring
within regional health authorities, priority be given to
ensuring there is balance of perspectives amongst those
participating. If the consultation is dealing with
disclosure to patients, the presence of a person or persons
who can articulate and advocate for the position of patients
is required. |
Currently each RHA has an ethics committee set up under a
framework designed to ensure a balance of perspectives.
Western Health, Central Health, and Labrador-Grenfell Health
currently have an informal process for accessing Eastern
Health's ethicists. The department is facilitating
discussions between Eastern Health and the other RHAs with a
view to formalizing the participation of Eastern Health's
ethicists as needed / upon request. |
Substantially complete |
|
55 |
It is
recommended that each regional health authority's disclosure
policies be reviewed periodically to ensure compliance with
current standards. Audits should be undertaken by each
regional health authority to ensure that policies are
current and that staff are aware of and comply with
policies. |
As part of its commitment to assist RHAs in providing
quality health care services the department is in the
process of establishing a provincial coordinating office for
adverse health event management. The coordinating office
will ensure that RHA policies pertaining to disclosure are
in place, current, reviewed periodically and complied with.
Additionally, an efficiency and effectiveness evaluation of
the provincial occurrence information system will be
conducted every three years. The department has initiated
recruitment of the coordinator for the provincial
coordinating office. |
Completed |
|
56 |
It is
recommended that the regional health authorities post
policies and procedures relevant to disclosure and patient
safety on their respective websites and make them available
to the public on request. To demonstrate their commitment to
the principle of transparency and to assist in rebuilding
public confidence in the healthcare system, any assessment
or accreditation of the regional health authority relating
to patient safety indicators should also be posted on the
website and made available to the public. |
All RHAs have posted their disclosure policy on their
respective websites. The RHAs are undergoing accreditation
in 2010, through Accreditation Canada, and patient safety is
one of eight quality dimensions measured. Once this process
is completed and reports received, the accreditation results
will be posted to RHA websites. As well,
assessments or accreditation of the regional
health authorities relating to patient safety indicators,
collected outside of the Accreditation Canada process, will
be posted.
|
Completed |
|
57 |
All
regional health authorities must preserve communications
related to an adverse event, including all forms of
electronic communication. Each regional health authority
should develop a policy to that effect and educate its staff
as to the importance of adhering to the policy. |
Three RHAs are revising existing policies to incorporate all
elements of this recommendation. These RHAs will finalize
their policies by March 2010. A fourth RHA will finalize its
policy by August 31, 2010. All RHAs will preserve electronic
communications related to an adverse event. Staff will be
educated as to the importance of adhering to the policy. |
Substantially complete |
|
58 |
"Patient
navigator" positions should be created within each hospital.
The primary responsibility of the patient navigator would be
to communicate with and on behalf of the patient. These
individuals would, among other things, assist patients
and/or their families in dealing or communicating with the
hospital. |
The department has initiated implementation of patient
navigators with a focus on cancer care. As a first step,
six patient navigator positions have been approved as part
of budget 2009-10. Three positions have been allocated to
Eastern Health and one to each of Central Health, Western
Health and Labrador-Grenfell Health. These positions will
be evaluated to ensure they are adequately responding to
patient demand and need, and if required, the department
will provide funding for more positions. The department has
assigned the provincial chief nursing officer with
responsibilities for leadership of implementing patient
navigators throughout the province. A provincial
coordinator will be in place in the coming weeks and
recruitment for patient navigators is underway. |
Substantially
complete |
|
59 |
The Government
of Newfoundland and Labrador should provide sufficient
funding to implement the recommendations contained in this
report. |
|
Completed |
|
60 |
The Minister of
Health and Community Services should report to the House of
Assembly on the status of implementation of the
recommendations contained in this report by March 31, 2010. |
|
Completed |