Since its inception in 2003, the National Society for Histotechnology (NSH) and the College of American Pathologists (CAP)'s joint venture, HistoQIP, helps more than 900 laboratories evaluate their histologic slide preparation, with a new biopsy program reaching more than 200 labs.

In the Beginning

With no histology quality improvement program existing for the anatomic pathology laboratory on the national level, NSH members envisioned HistoQIP and approached CAP to collaborate on the idea.

"The main reason [HistoQIP] was started was to create a quality improvement program ensuring labs are preparing slides that are adequate for proper pathology analysis and proper diagnosis," explained Saeid Movahedi-Lankarani, MD, a member of Hospital Pathology Associates (HPA) in Minneapolis/St. Paul, where he serves as the co-director of the Division of Gynecologic Pathology for HPA. He is also the chair of the CAP/NSH Histotechnology Committee.

The program looks at the fixation of specimens, how they are processed, and how the slides are prepared, cut and stained. "We wanted to try and gather data to see how well labs are doing and to help the labs who are having problems with their histology programs," Dr. Movahedi-Lankarani told ADVANCE.

With heavy participation from Canadian labs as well, "HistoQIP is not only improving quality in the U.S., but also setting a level across the board," he added. "The quality of the H&E slide is important to make a high quality diagnosis. If you haven't fixed and cut the specimens properly, you affect everything. We are starting at square one to make sure every slide is done properly."

How It Works

After a laboratory signs up for the program, the histology department is sent one kit twice a year. The kit includes instructions on what tissue type needs to be used to cut a slide section and what stain needs to be performed on it. The kit also provides slide labels to ensure the anonymity of the participating lab. Five slides need to be prepared, and they are either a biopsy or a resection specimen, Dr. Movahedi-Lankarani said. Two slides are H&E stains, two are immunohistochemical stains and the last one is a histochemical slide.

Janet Tunnicliffe, MLT, ART, regional laboratory scientist, Anatomic Pathology, Fraser Health Authority, British Columbia, Canada; NSH Speaker of the House of Delegates; and CAP/NSH Histotechnology Committee member, explained histologists also fill out an online form about their site and what kind of equipments and reagents they use, which helps HistoQIP build its best practice database. After participating laboratories have prepared the slides, the slides are sent to CAP to be graded. A committee of pathologists and histotechnologists microscopically review each slide submitted.

"This mix is key because we all look at different things," Tunnicliffe said. "We need the support of the pathologist to make sure people have submitted the right types of tissue. We need the techs there because pathologists can recognize if something is wrong with the slide but they might not know exactly why."

Each slide reviewer goes through a 2-hour review on the program's criteria, how to grade the slide and what key things to look for. "This is done so we can guarantee we have consistence in grading, and we remove everyone's personal bias," Tunnicliffe added.

For a day and a half, the committee sits at microscopes and grades the slides individually. They evaluate the slides to see if they are good, average or unacceptable in the following categories: fixation, tissue processing and embedding, microtomy, staining and coverslipping. The results are then tabulated and compared. After that is completed, the tab sheets are sent back to the participants so they can review their evaluations, compare results to their peers and implement changes, if required, as well as possibly learning something new.

"With their grades, we send back a lot of educational material," Dr. Movahedi-Lankarani noted. "With each of these slides and stains performed, we have individuals write some nice, several pages long articles about that tissue and stain in particular, and how to best process the specimen, how to avoid errors particular to the tissue, how to avoid staining problems, etc."

Additionally, there is CME component to the HistoQIP program that can be accessed online, and any histotechnologist from a lab enrolled in the program can participate.

What's New

Since the program began, HistoQIP has been focusing more on immunohistochemistry and trying to get the word out about quality improvement of technical work.

"We've started to take marks off of the lab's score if they labeled the slides wrong," Tunnicliffe mentioned. "Really and truly, this is critical to the daily work flow. If you were to label Mrs. Smith's specimen with Mr. Jones's label, this would be a big problem."

In 2009, the committee released a book published by CAP, Histological Preparations: Common Problems and Their Solutions.

"We realized there are a lot of good instructional manuals out there that are like recipe books to tell you how to make the solutions, apply them and what results you get," Tunnicliffe explained. "There weren't any textbooks telling techs and pathologists what it looks like when something goes wrong. Most textbooks give you beautiful pictures of how things should work, but ours shows you what happens when something goes wrong, and what you can do to correct the problem. It's a good handbook for both technologists and pathologists to reference on a daily basis."

Additionally, this year the committee added the HistoQIP Biopsy Series. The committee realized a handful of the over 1,000 labs participating in their program are subspecialty labs, such as histology labs specializing in dermapathology or small biopsies. "A number of people were asking us to [alter the program to] have these labs included so they could submit tissues they routinely do on an annual basis, rather than submitting tissues they didn't have available," Dr. Movahedi-Lankarani said. "Biopsies in terms of volume are a lot more common than major resections. We're basically the only program who looks at these parameters."

Similar to the regular program, the 2010 NSH/CAP HistoQIP Biopsy Series will send these laboratories two kits a year and asks them to prepare the following slides: bladder biopsy, cervical biopsy, skin punch biopsy, stomach biopsy, colon biopsy, endometrial biopsy/curettage, prostate biopsy and skin excisional biopsy.

'The Highest Priority'

Through its programs and book, the HistoQIP committee aims to improve the quality of histology slides and hopes to help its participating labs learn more about their important task.

"The preparation of tissue and H&E is the highest priority in the lab," Tunnicliffe stressed. "If that's not good, the pathologists order more work, causing more delays and more costs."

To order the HistoQIP program, call CAP at 800-323-4040, option 1.

Amanda Koehler (akoehler@advanceweb.com) is associate editor of ADVANCE.