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Nongynecologic cytology turnaround time: a College of American Pathologists Q-Probes study of 180 laboratories. (CAP Laboratory Improvement Programs).

The College of American Pathologists Q-Probes program is designed to study laboratory quality and promote quality improvement. Laboratory test turnaround time is a measure of laboratory service quality that has been studied extensively by the Q-Probes method. Previous Q-Probes studies have examined turnaround times for gynecologic cytology, routine and complex surgical specimens, cerebrospinal fluid examinations, stat and routine clinical laboratory testing, operating room blood delivery, and autopsy reports. (1-11) Nongynecologic cytology represents a variety of studies that are important diagnostic components for acute and chronic patient care, both inpatient and outpatient. A timely evaluation and report facilitates efficient patient care and is expected in a competitive, customer service-oriented health care system. The College of American Pathologists Laboratory Accreditation Program has recently added a checklist item regarding turnaround time performance for nongynecologic cytology, (12) as they have previously for surgical pathology turnaround times. (13)

This Q-Probes study examined nongynecologic cytology turnaround time and laboratory practices and specimen characteristics potentially associated with turnaround time performance. To our knowledge, no comparable study or database of nongynecologic cytology turnaround time has been published previously.

METHODS

Laboratories participating in the College of American Pathologists Q-Probes program during the first trimester of 2000 collected data for 60 consecutive workdays or until 120 cases were accumulated, whichever occurred first. The Q-Probes study design and data-handling methodology have been described previously. (14) To control sampling bias, each laboratory was instructed to select cases at appropriately equal intervals so that 2 were selected each day, based on the individual laboratory's case volume (daily case volume divided by 2 equals the interval between study cases). We recorded the following data for each case.

1. Date of specimen collection.

2. Date of specimen receipt in the laboratory (the initial contact point, whether it was received in a central processing/receiving area or the cytopathology laboratory itself).

3. Date of final report sign-off. If the test was performed in the participant's laboratory, this was the date when the manual or electronic signature was applied to the final report. If the test was performed in a reference laboratory, this was the date that the report was returned to the participant's laboratory for distribution. If the reference laboratory reported directly to clinicians, this was the date when the reporting took place.

4. The specimen type, selected from the following provided list:

* Sputum

* Fluid specimen (cerebrospinal, pleural, peritoneal, bronchial washing, urine, etc)

* Brushing specimen, any site

* Fine-needle aspiration (FNA), any site

* Other

5. The diagnosis category, selected from the following provided list. (No additional definitions were provided for these diagnostic categories. Participants were asked to apply their diagnoses in the context of the diagnosis options provided.)

* Unsatisfactory

* Negative/benign changes/no evidence of malignancy or equivalent

* Atypical/suspicious for malignancy or equivalent

* Malignant

* Nondiagnostic

6. Other activities, recording all that apply from the following provided list:

* Resident or fellow involved in the diagnostic evaluation

* Old slides (cytology or histology) pulled for review before sign out

* Physician contacted for additional information

* Cytotechnology student screening

* Cell block performed

* Special stains performed (conventional or immunohistochemical stains)

* Centrifugation or cytocentrifugation

* Thin layer preparation

* Other activity adding (or potentially adding) to laboratory evaluation time

7. For FNAs only, whether the specimen was collected by a pathologist or nonpathologist physician.

All recorded dates and turnaround time calculations used calendar days. No adjustments were made for interruptions in specimen processing and reporting due to weekends or holidays.

Each laboratory also completed a questionnaire providing information about their laboratory, including case volume; average number of cytologic slides per nongynecologic cytology cases; whether slide processing or screening functions were performed at off-site locations (sites other than where pathologists reviewed slides); whether transcription was performed within the laboratory or outside the laboratory; whether cytotechnologists, preparatory technicians, transcriptionists, or pathologists routinely worked on Saturday, Sunday, or both; whether the laboratory had written definitions or goals for nongynecologic cytology turnaround time; whether pathologists reviewing nongynecologic cytology cases were board certified (added qualification) in cytopathology; the frequency with which diagnoses were called to clinicians; the frequency with which thin-layer processing was utilized; and the availability of electronic and paper reporting for inpatients.

Associations between turnaround time and practice variables were identified using Kruskal-Wallis tests for discrete-valued independent variables and regression analysis for continuous-valued independent variables. (15,16)

RESULTS

One hundred eighty laboratories (174 located in the United States, 3 in Canada, 2 in Australia, and 1 in the United Kingdom) submitted data for all or part of the study. The majority of participants described themselves as private, nonprofit hospital laboratories (61.7%). The remainder included state, county, and city hospitals (12.8%), private for-profit hospitals (5.4%), independent laboratories (4.7%), university hospitals (3.4%), federal government hospitals (3.4%), and others (8.7%). Participating laboratories submitted turnaround time data for 16 950 nongynecologic cytology cases, of which 25 were excluded due to incomplete data, leaving 16925 cases for analysis. Table 1 summarizes the participants' case volume and cytology slides per case data (excluding cell blocks).

Fifteen (8.8%) of 171 laboratories reported that slide processing and screening were performed off-site, and 16 (9.4%) of 170 reported that transcription was performed outside the laboratory. Routine weekend work (Saturday and/or Sunday) was performed by cytotechnologists in 10 (5.9%) of 169 laboratories laboratories, by preparatory technicians in 31 (18.2%) of 170 laboratories, by transcriptionists in 36 (21.2%) of 170 laboratories, and by pathologists in 30 (17.5%) of 171 laboratories. One hundred sixteen (68.6%) of 169 laboratories reported employing pathologists with subspecialty board certification in cytopathology. One hundred ten (65.5%) of 168 laboratories reported having written definitions or goals for nongynecologic cytology turnaround time. Fifty-nine (34.9%) of 169 laboratories reported using thin-layer processing for nongynecologic cytology specimens. In 115 (67.7%) of 170 institutions, inpatient reports were made available electronically to the clinicians as soon as they were signed out. On average, laboratories reported placing 69.9% of printed reports on inpatient charts the same day they were signed out, 33.2% the day following sign-out, and 12.1% 2 or more days after they were signed out. Table 2 summarizes, by diagnosis, the frequency with which reports were called to clinicians.

Table 3 summarizes the specific characteristics of the study cases. The majority of specimens were fluids. The majority of cases were given negative or benign diagnoses.

Centrifugation was the most common additional procedure performed on the specimens. In aggregate, 18.5% of cases were signed out the same day they were received, 64.0% within 1 day, 75.7% within 2 days, 86.6% within 3 days, and 92.8% within 4 days.

Table 4 summarizes the distribution of mean and 90th percentile turnaround times in calendar days for all 180 participating institutions. For example, 10% of participating laboratories had a mean specimen collection to report sign-off turnaround time of 4.0 days or longer, 50% of laboratories had mean specimen collection to report sign-off turnaround times of 2.1 days or longer, and 90% of laboratories had mean specimen collection to report sign-off turnaround times of 1.2 days or longer. Similarly, 10% of participating laboratories reported 90% of their cases in 7.0 days or longer from specimen collection to final report sign-off, 50% of laboratories reported 90% of their cases in 4.0 days or longer, and 90% of laboratories reported 90% of their cases in 3.0 days or longer.

Table 5 lists mean case intralaboratory (receipt to final report sign-off) turnaround times by individual case characteristics. Significantly longer turnaround times were associated with processing fluid and FNA specimens; issuing atypical/suspicious for malignancy and nondiagnostic diagnoses; having cytotechnology students screen slides; having to contact physicians for additional information; having to pull prior case material for review; and having to perform cell blocks, special stains, or other ancillary activities. Laboratory practice characteristics that were significantly associated with longer mean turnaround times included screening or processing slides off-site (with off-site screening, 2.5 days; no off-site screening, 1.7 days) and not having transcriptionists work on weekends (not working weekends, 1.8 days; working weekends, 1.5 days).

Table 6 provides a breakdown of the percentage of diagnoses per specimen type, and Table 7 provides a breakdown of the percentage of "Other" activities by specimen type.

COMMENT

It has been repeatedly pointed out that test turnaround time is a significant quality factor in our service-oriented laboratory industry. (11,17) In contrast to gynecologic cytology, which serves primarily as a screening test, nongynecologic cytology represents a mixture of screening and acute diagnostic testing. Fine-needle aspiration in particular is an acute diagnostic method for which rapid turnaround time has been promoted as one of several advantages over biopsy. (18,19) The overall shorter turnaround times for nongynecologic cytology seen in this study (Table 8), when compared to the previous Q-Probes study of gynecology cytology, (11) is probably related in part to a difference in case priority. Some laboratories may find it beneficial to study the differences in specimen processing and handling for gynecologic and nongynecologic cytology.

We measured turnaround time in calendar days, without adjusting for weekends or holidays, because we believe that clinicians may perceive the quality of laboratory turnaround time in this interval, rather than in terms of working days. Measuring turnaround time in calendar days also allowed us to compare the performance of laboratories that chose to provide weekend and holiday service with the performance of those that chose not to provide such service.

Of the 5 specimen types reported for this study, the mean turnaround times were longer for fluids and FNAs (1.8 and 1.9 days, respectively) than they were for sputum (1.7 days), brushings (1.5 days), and other types of specimens (1.4 days). Although fluids and FNAs require more processing than the other specimens, utilization of centrifugation and thin-layer preparation, more commonly used in processing fluids and FNAs, was not associated with longer turnaround times. Cell block preparations were more commonly utilized in processing fluids and FNAs and were associated with longer turnaround times. Focusing on the process of preparing and interpreting cell blocks might be one place to begin an analysis of potential opportunities for improvement. Communicating preliminary results to clinicians, pending cell block results, may also improve turnaround time, the clinician's perception of service, or both.

Cases diagnosed as atypical/suspicious for malignancy and nondiagnostic, as well as cases requiring special stains, exhibited slightly longer turnaround times. This difference most likely represents the prolonged review that these types of cases frequently require, including internal consultations. Similar to the findings of a previous Q-Probes study, (6) contacting physicians for additional information and pulling old slides for review also added to turnaround time delays. Contacting physicians and pulling old slides resulted in the longest delays (mean turnaround times of 3.0 and 3.2 days). Although a relative minority of specimens required these activities (2.0% and 2.3%), in many laboratories they may generate a disproportionately large number of complaints and perceptions of service dissatisfaction. Therefore, improving the processes of contacting physicians and pulling old slides may shorten turnaround time and improve perceptions of service. Activities such as educating physician office staff with regard to supplying the necessary information on requisitions, or modifying requisitions to make them more user friendly, should also be considered.

As was previously demonstrated in the Q-Probes study on gynecologic cytology turnaround time, (11) off-site specimen processing or screening resulted in a mean turnaround time delay of almost 1 day. However, not all hospitals and laboratories can manage on-site cytopathology services. In these circumstances, close examination of the processes that send specimens out for processing and return the slides for pathologist interpretation should be performed and optimized.

In contrast to the results of the previous Q-Probes study of gynecologic cytology turnaround time, (11) but similar to the results of other Q-Probes studies dealing with turnaround times in anatomic pathology, (5,9) this study found shorter turnaround times for institutions routinely performing transcription on weekends.

Laboratories reported that, on average, a third of inpatient reports were placed on the charts a day or more after the report was signed out. This may reflect poorly on turnaround time service unless an alternative and more timely method of communicating results to clinicians has been used. In this study, significant numbers of critical diagnoses, including those with malignant or infectious findings, were not called in to clinicians and may have resulted in delayed treatments and prolonged hospital stays.

Similar to results of previous Q-Probes studies, (2,8,11) laboratory policies of setting turnaround time goals or standards were again shown to have no association with turnaround time performance. Proclaiming goals accomplishes little unless appropriate attention is paid to designing, monitoring, and adjusting processes to accomplish those goals. Furthermore, turnaround time expectations that are appropriate for various health care settings and circumstances must be developed jointly with medical staff members. A given turnaround time performance may be acceptable for patient care in one situation, but unacceptable in another. The goal should be to meet the local needs.

Fine-needle aspirations exhibited the highest frequency of malignant diagnoses, as well as the highest frequency of nondiagnostic findings. Sputum had the highest frequency of unsatisfactory specimens. When the unsatisfactory and nondiagnostic categories were combined, FNAs were the clear leader in the frequency with which there was a failure to provide clinically useful information. When broken down by whether the specimen was obtained by a pathologist or nonpathologist physician, a significant reduction in the combined categories of unsatisfactory and nondiagnostic was noted when the specimen was collected by pathologists (10.0% vs 15.1%). Where individual institutions identify high rates of unsatisfactory and/or nondiagnostic FNA reports, working with clinicians to improve the quality of the aspiration and specimen should be considered. Alternatively, if a qualified cytopathologist is available, setting up a pathologist FNA service is another alternative to improve the service.

We believe that this study, like the prior Q-Probes study of gynecologic cytology turnaround time, (11) characterizes the current state of nongynecologic cytology turnaround time, and that the results can be used for benchmarking comparisons of process and performance. Using the data from this study, a laboratory would be in the top 50% of performers if its mean collection to reporting turnaround time is 2.1 calendar days or less (receipt to report in 1.6 calendar days or less), and 90% of cases are reported in 4.0 calendar days or less (receipt to report in 3.0 calendar days or less). It is reasonable to expect that nongynecologic cytology service would approximate that of a surgical pathology biopsy specimen. Zarbo et al (5) reported that 95% of routine biopsies were reported within 2 working days of laboratory receipt. A turnaround time of 2 working days translates roughly into the equivalent of 3 calendar days. Ideally, all laboratories would initiate a formal analysis of their nongynecologic cytology processes, similar to an analysis reported in an abstract by Zaleski et al (20) for gynecologic cytology (in response to the prior Q-Probes study of gynecologic cytology turnaround time (11)), which resulted in cutting their turnaround time in half. Laboratories should identify and focus on specific customer needs for turnaround time service. A complete weekend service may not be needed if a primary concern is the 2-day delay for Friday afternoon specimens. A late Friday evening service or a Saturday morning service may provide a satisfactory solution to a focused issue such as this.

As was pointed out before, (11) turnaround time is only 1 component of cytopathology service quality. The quality of the diagnostic evaluation of the specimen should never be compromised in an effort to improve turnaround time. High-quality evaluation and good turnaround time service are not necessarily mutually exclusive.
Table 1. Laboratory Nongynecologic Cytology Case Volume and Average
Number of Cytology Slides per Case

 All Institutions
 Percentiles

 No. of
 Institut- 50th
 ions * Mean 10th (Median) 90th

Yearly nongynecologic
 cytology case
 volume 171 1853.0 336 1118 3649

Slides per case
 All cases 169 3.2 2 3 5
 Sputum 167 2.5 1 2 4
 Washings 168 2.8 1 2 4
 Brushings 167 2.7 1 2 5
 Urine 168 1.9 1 2 4
 Cerebrospinal fluid 167 2.1 1 2 4
 Other fluids 168 2.9 1 3 4
 Fine-needle
 aspirations 168 5.8 2 6 10

* Not all participating laboratories submitted complete data sets.
Table 2. The Institutional Reported Frequency (Percentage) of Calling
Reports to Clinicians, by Diagnosis Category

 Diagnosis Category

 Atypical/
 Suspicious
 for Infectious Negative/
 Call Reports Malignant Malignancy Organism Benign

Always (>95%) 34.9 16.6 17.9 0.6
Usually (76%-95%) 23.7 13.0 14.9 0.6
Often (51%-75%) 16.6 21.3 9.5 0.6
Sometimes (26%-50%) 10.7 24.3 19.1 14.3
Rarely (5%-25%) 10.7 16.0 28.0 44.6
Never (<5%) 3.6 8.9 10.7 39.3
Table 3. Case Characteristics

 Percentage
 Case Characteristic of All Cases

Specimen type (N = 16 915 cases)
 Sputum 4.7
 Fluid 61.5
 Brushing 8.0
 Fine-needle aspiration 23.4
 Other 2.4

Diagnosis category (N = 16 827 cases)
 Unsatisfactory 2.6
 Negative/benign changes 71.9
 Atypical/suspicious for malignancy 11.4
 Malignant 11.3
 Nondiagnostic 2.8

Other activities related to cases
 (N = 13 284 cases)
 Centrifugation 68.0
 Cell block prepared 37.5
 Thin-layer preparation 33.1
 Other activity adding to evaluation time 11.6
 Special stains 8.0
 Resident or fellow involved 7.3
 Old slides pulled for review 2.3
 Physician contacted for additional
 information 2.0
 Cytotechnology student screening 1.4
Table 4. Distribution of Mean and 90th Percentile Nongynecologic
Cytology Turnaround Times

 Percentile

 50th
 (Med-
 Turnaround Time Interval 10th ian) 90th

Mean turnaround time, d
 Specimen collection to receipt 1.2 0.5 0.0
 Receipt in laboratory to final report sign-off 3.2 1.6 0.8
 Specimen collection to final report sign-off 4.0 2.1 1.2

90th percentile turnaround times, d *
 Specimen collection to receipt 3.0 1.0 0.0
 Receipt in laboratory to final report sign-off 6.0 3.0 1.0
 Specimen collection to final report sign-off 7.0 4.0 3.0

* The time within which a laboratory has completed 90% of its cases.
Table 5. Listings of Case Characteristics and Mean
Intralaboratory Turnaround Times

 Mean
 No. of Turnaround
 Case Characteristic Cases Time, d

Specimen type
 Sputum 794 1.7
 Brushing 1356 1.5
 Fluid 10 389 1.8 *
 Fine-needle aspiration 3947 1.9 *
 Other 411 1.4

Diagnosis
 Unsatisfactory 440 1.8
 Negative/benign changes 12 081 1.7
 Atypical/suspicious for malignancy 1908 2.0 *
 Malignant 1906 1.8
 Nondiagnostic 477 1.9 *

Other
 Cytotechnology student screening 192 2.1 *
 Physician contact for additional
 information 266 3.0 *
 Old slides pulled for review 303 3.2 *
 Cell block performed 4971 2.1 *
 Special stains performed 1058 2.0 *
 Resident/fellow involved 969 1.7
 Centrifugation 9011 1.8
 Thin-layer preparation 4391 1.7
 Other activity 1536 2.2 *

* Significantly longer intralaboratory turnaround times (P < .05).
Table 6. Breakdown of Diagnoses by Specimen Type

 Diagnosis Category, %

 No. Aty-
 of Un- pical/ Non-
 Cases satis- Nega- Suspi- Malig- diag-
 Specimen Type * factory tive cious nant nostic

Sputum 791 10.5 74.6 9.2 4.9 0.8
Fluid 10 340 0.8 78.9 11.7 7.5 1.0
Brushing 1348 1.1 67.4 12.7 17.7 1.1

Fine-needle
 aspiration
 collected by:
 Pathologist 361 4.4 59.0 9.1 21.9 5.5
 Nonpathologist
 physician 3481 6.4 52.5 11.2 21.2 8.8

Other specimen 409 3.7 80.9 5.6 3.7 6.1
All cases 16 730 2.6 71.9 11.4 11.3 2.8

* Not all participating laboratories submitted complete data sets.
Table 7. Breakdown of Other Activities Related to Cases By Specimen
Type *

 Cyto-
 techno-
 No Resi- Phy- logy
 No. of Other dent Old sician Student
 Specimen Cases Acti- In- Slides Cont- Screen-
 Type ([dagger]) vity volved Pulled acted ing

Sputum 794 35.9 5.8 0.5 0.8 0.6
Fluid
 specimen 10 399 14.0 5.0 1.4 1.0 1.3
Brushing
 specimen 1358 41.5 5.0 2.1 1.7 0.4
Fine-needle
 aspiration 3953 27.6 8.3 3.0 2.9 1.2
Other 411 61.1 2.7 1.2 3.6 1.0

 Cell Special Thin-
 Block Stains Layer
 Specimen Per- Per- Centri- Prepa-
 Type formed formed fugation ration Other

Sputum 26.3 8.1 25.8 18.6 10.8
Fluid
 specimen 31.3 4.9 65.1 28.7 7.6
Brushing
 specimen 17.6 3.8 30.4 19.4 14.6
Fine-needle
 aspiration 31.0 10.2 39.6 24.3 10.9
Other 10.7 6.8 17.0 7.5 8.5

* Participants were able to select more than 1 activity per case.
Percentages therefore do not total 100%.

([dagger]) Not all participating laboratories submitted complete
data sets.
Table 8. Comparison of the Intralaboratory Mean and 90th Percentile
Turnaround Times for Nongynecologic and Gynecologic Cytology

 Interinstitutional
 Percentile

 Intralaboratory Turnaround Time 50th
 (Receipt to Final Report Sign-off) 10th (Median) 90th

Mean turnaround time, d
 Nongynecologic cytology 3.2 1.6 0.8
 Gynecologic cytology (11) 11.7 4.4 1.6

90th percentile turnaround times, d *
 Nongynecologic cytology 6.0 3.0 1.0
 Gynecologic cytology (11) 17.0 7.0 3.0

* The time within which a laboratory has completed 90% of its cases.


References

(1.) Howanitz PJ, Steindel SJ. Intralaboratory performance and laboratorians' expectations for stat turnaround times: a College of American Pathologists Q-Probes study of four cerebrospinal fluid determinations. Arch Pathol Lab Med. 1991;115: 977-983.

(2.) Howanitz PJ, Steindel SJ, Cembrowski GS, Long TA. Emergency department stat test turnaround times: a College of American Pathologists Q-Probes study for potassium and hemoglobin. Arch Pathol Lab Med. 1992;116:122-128.

(3.) Howanitz PJ, Cembrowski GS, Steindel SJ, Long TA. Physician goals and laboratory test turnaround times: a College of American Pathologists Q-Probes study of 2763 clinicians and 722 institutions. Arch Pathol Lab Med. 1993;117: 22-28.

(4.) Steindel SJ. Timeliness of clinical laboratory tests: a discussion based on five College of American Pathologists Q-Probes studies. Arch Pathol Lab Med. 1995; 119:918-923.

(5.) Zarbo RJ, Gephardt GN, Howanitz PJ. Intralaboratory timeliness of surgical pathology reports: results of two College of American Pathologists Q-Probes studies of biopsies and complex specimens. Arch Pathol Lab Med. 1996;120:234-244.

(6.) Novis DA, Zarbo RJ. Interinstitutional comparison of frozen section turnaround time: a College of American Pathologists Q-Probes study of 32,868 frozen sections in 700 hospitals. Arch Pathol Lab Med. 1997;121:559-567.

(7.) Howanitz PJ, Saladino AJ, Dale JC. Timeliness of urinalysis: a College of American Pathologists Q-Probes study of 346 small hospitals. Arch Pathol Lab Med. 1997;121:667-672.

(8.) Steindel SJ, Howanitz PJ. Changes in emergency department turnaround time performance from 1990 to 1993: comparison of two College of American Pathologists Q-Probes studies. Arch Pathol Lab Med. 1997;121:1031-1041.

(9.) Novis DA, Zarbo RJ, Saladino AJ. Interinstitutional comparison of surgical biopsy diagnosis turnaround time: a College of American Pathologists Q-Probes study of 5384 surgical biopsies in 157 small hospitals. Arch Pathol Lab Med. 1998;122:951-956.

(10.) Steindel SJ, Novis DA. Using outlier events to monitor test turnaround time: a College of American Pathologists Q-Probes study in 496 laboratories. Arch Pathol Lab Med. 1999;123:607-614.

(11.) Jones BA, Valenstein PN, Steindel SJ. Gynecologic cytology turnaround time: a College of American Pathologists Q-Probes study of 371 laboratories. Arch Pathol Lab Med. 1999;123:682-686.

(12.) College of American Pathologists Laboratory Accreditation Program Cytopathology Checklist 8A (Proposed). Question 08A:BBCC. Northfield, Ill: College of American Pathologists; April 1999.

(13.) College of American Pathologists Laboratory Accreditation Program Anatomic Pathology Checklist 8 (Proposed). Question 08:1215. Northfield, Ill: College of American Pathologists; March 1999.

(14.) Howanitz PJ. Quality assurance measurements in departments of pathology and laboratory medicine. Arch Pathol Lab Med. 1990; 114:1131-1135.

(15.) Hollander M, Wolfe DA. Nonparametric Statistical Methods. New York, NY: John Wiley & Sons; 1973.

(16.) Draper NR, Smith H. Applied Regression Analysis. 2nd ed. New York, NY: John Wiley & Sons Inc; 1981.

(17.) Valenstein P. Laboratory turnaround time. Am J Clin Pathol. 1996;105: 676-688.

(18.) Guidelines of the Papanicolaou Society of Cytopathology for fine-needle aspiration procedure and reporting: the Papanicolaou Society of Cytopathology Task Force on Standards of Practice. Mod Pathol. 1997;10:739-747.

(19.) Costa MJ, Campman SC, Davis RL, Howell LP. Fine-needle aspiration cytology of sarcoma: retrospective review of diagnostic utility and specificity. Diagn Cytopathol. 1996;15:23-32.

(20.) Zaleski S, Persoon T, Cohen M. Reducing Pap smear turnaround time (TAT) by applying industrial engineering and organizational development tools [abstract]. Acta Cytol. 2000;44:875.

Accepted for publication May 9, 2001.

From the Department of Pathology, St John Hospital and Medical Center, Detroit, Mich (Dr Jones); Department of Pathology, Wentworth-Douglass Hospital, Dover, NH (Dr Novis).

Reprints: Bruce A. Jones, MD, St John Hospital and Medical Center, Department of Pathology, 22101 Moross Rd, Detroit, MI 48236 (e-mail: bruce.jones@stjohn.org).
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Author:Jones, Bruce A.; Novis, David A.
Publication:Archives of Pathology & Laboratory Medicine
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Date:Oct 1, 2001
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