Bristol Haemato-Oncology Diagnostic Quality Measures

Internal quality assurance

Standard operating procedures are used for diagnostic investigation and consistent reporting. BHODS uses the following approaches to maintain quality of sample processing and results reporting.

A SOP dealing with for registration of patient details, clinical information and recording of samples received.

A SOP by tissue type for initial and subsequent investigation panels.

A SOP for reporting and authorisation.

A SOP based on the WHO 2017 classification gives the diagnostic standards for haematological malignancies. It identifies the disease to be diagnosed, ICD / SNOMED code, relevant prognostic factors and any differences from the WHO criteria in making the diagnosis if appropriate.

Interim reports may be issued when the diagnosis is made but additional information such as that required for prognosis is pending Interim reports will be finalised with a “Final report” and any corrections to a final report will be amended with an “addendum” report.

A typical, unusual or rare cases will be independently checked before authorisation and report issue.

SOP's are reviewed annually and are in line with those of other similar diagnostic services.

Trusts sending samples to BHODS are offered regular input for clinical MDT meetings Laboratory IT systems are used to check reporting accuracy, reporting concordance and reporting times.

The process of multidisciplinary investigation of Haematological Malignancy will result in a small number of cases where either diagnostic modalities or reporting clinicians are unable to define a single unifying diagnosis. These cases are subject to multi-disciplinary review within NBT SIHMDS Diagnostic Review Meeting.