2011, Volume 27, Number 3, Page(s) 235-245
Pathology Laboratories Productivity Evaluation in Turkey
Kutsal YÖRÜKOĞLU1, Sarp ÜNER2, Fevzi HARORLU3, Alp USUBÜTÜN4
1Department of Pathology, Dokuz Eylül University, Faculty of Medicine, İZMİR, TURKEY
2Department of Public Health Hacettepe University, Faculty of Medicine, ANKARA, TURKEY
3Department of Pathology, Bursa Ali Osman Sönmez Oncology Hospital, BURSA, TURKEY
4Department of Pathology, Hacettepe University, Faculty of Medicine, ANKARA, TURKEY
Keywords: Pathology, Laboratory, Workflow, Productivity, Automation, Survey
Efficiency criteria and automation in pathology laboratories
have been set in a limited number of studies usually originated from
the United States. A questionnaire has been prepared to determine
the situation and define the criteria for adaptation in our country.
Material and Method: The survey was sent to all pathology
laboratories and, 302 responded. The survey questionned of
pathology laboratories efficiencies, staff workloads, methods applied,
devices used, and physical conditions. Work flow productivity
was obtained by dividing the annual number of blocks to working
hours multiplied by the number of technicians. The hospitals were
categorized to 3 groups according to providing training or not and
privacy, and to 4 groups according to the annual biopsy numbers.
The data entered through the SPSS 16.0 statistical package program,
analysis of distribution criteria, significance of the difference between
means tests were used.
Results: The annual biopsy numbers were significantly higher
in education units, but below the limit of productivity levels for
all laboratories. The device hardware and automation correlated
with annual biopsy numbers. However, the laboratories of
limited capacity have redundant automation. Histochemical and
immunohistochemical staining numbers were high. Liquid-based
cytology techniques were used more significantly in private hospitals.
Archiving times were not standard. A serious shortage of working
space in service hospitals was noted. Work flow productivity in
education units was at the border, and low in other units.
Conclusion: All pathology laboratories in our country should define
and improve their productivities. Formalizing of archiving times is
very important for future malpractice lawsuits.
The pathology report is the product in pathology. The
major sources for the generation of this report are
macroscopic and microscopic investigations. Proper
sampling and processing of tissues and liquids are required
for microscopic investigations. Processing of tissues and
liquids is a long process and all the steps of this process can
be done manually. However, in laboratories in which the
number of materials is high, it is desired to automate almost
all of the operations with the use of devices in order to rush
and standardize the work, and to obtain the product with
lower number of workers at lower cost. Similar automation
processes are also valid for conventional histochemistry
and immunohistochemistry techniques, which are used
besides histological Hematoxylin-Eosin (H&E) and
cytological H&E or similar (like Papanicolaou) stained
smears required for standard microscopic investigations.
Technological advancements cause cheapening of devices
day by day in pathology, as it does in general industry1
However, it cannot be denied that redundant devices are
being purchased for some manually executable and easy
In a nationally-scaled survey carried out by the
Standardization Commission of the Turkish Federation
of Pathology Societies, it was shown that automation was
related to the number of materials and the establishment
date of the unit in our country2. In another survey
performed on an international scale, working conditions
in pathology laboratories were determined globally, and
the most productive threshold values for automation were
A new survey study for pathology laboratories of public
hospitals in Turkey was carried out by the Standardization
Commission of the Turkish Federation of Pathology
Societies with the support of the Ministry of Health, and the
distribution and productivity of country-wide pathology
laboratories, and the workload of workers employed in
these laboratories were presented as an article4. Here,
the results of the same survey are evaluated in terms of
automation and laboratory productivity.
The universe of the descriptive study consisted of Ministry
of Health hospitals, university hospitals, and private
hospitals which have pathology laboratories. No sample
was chosen and we tried to reach all of the hospitals.
The number of beds, number and distribution of materials,
units sending materials, devices used, methods employed, laboratories and working spaces, quality and number of
workers, and required time for reporting and archiving
were questioned with the survey form prepared.
Work Flow Productivity (WFP) was obtained by dividing
the annual block number by multiplication of annual work
hours and number of technicians (Work Flow Productivity
= Annual block number / 2080 x number of technicians).
Hospitals were separated into 3 groups as training, nontraining
and private, and all of the laboratories were divided
into 4 groups according to the number of material received
as <10.000, 10.001-20.000, 20.001-30.000, and >30.001.
Differences between the groups were calculated.
Data were entered using the SPSS 16.0 statistical package
program, and distribution measures were used for analyses
while variance analyses were used to determine whether
there was a significant difference between measurement
values when there were more than two groups. When the
differences between the groups were determined to be
significant, the group the significance originated from was
assessed with the LSD (least significant difference) test, one
of the “post-hoc” tests.
The survey was sent to all of the hospitals, and 302 hospitals
(35 University [UH], 41 Ministry of Health Training
[TH], 185 Ministry of Health Service [SH] and 41 Private
Hospitals [PH]) replied.
The distribution of these pathology units according to their
number of biopsies is presented in Table I. Biopsy numbers
were greater in UH and TH.
Annual biopsy, cytology, intra-operative consultation, block
and slide numbers varied considerably between hospitals
(p<0.01) (Table II). All parameters were greater in UH and
TH compared to other hospitals.
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|Table II: Distribution of hospitals’ annual biopsy, cytology, intra-operative consultation, block and slide numbers
These variables correlated positively with the number of
beds, and this relation was statistically significant (p<0.01,
When the hospitals were grouped according to their number
of biopsies, the number of slides per block was greater in
units with 20.001-30.001 biopsies, but the number of blocks
per biopsy was also smaller in these units (Table III).
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|Table III: Number of blocks per biopsy and slides per block for hospitals grouped according to number of biopsies
Evaluation of the distribution of devices used in routine
work showed that the numbers of macroscopy cabinets,
microtomes, frozen devices, and light microscopes varied
between the hospitals (Table IV). However, the number of
cytocentrifuge devices showed no difference.
The number of light microscopes correlated with the number
of biopsies (p<0.001). There was one microscope per 5.077
biopsies on average. Similarly, the number of annual
biopsies also correlated with the number of microtomes
(p<0.001, 1 for 5.077 biopsies), macroscopy cabinets
(p<0.001, 1 for 5.108 biopsies), tissue processing devices
(p<0.001, 1 for 5.108 biopsies), tissue embedding devices
(p<0.001, 1 for 5.108 biopsies), frozen devices (p<0.001, 1
for 5.108 biopsies), and macroscopic photography devices
(p<0.001, 1 for 5.108 biopsies).
The numbers of automatic tissue processing devices,
tissue embedding devices, automatic slide staining
devices, automatic slide mounting devices, cassette and
slide printers, automatic immune staining devices and
macroscopy dissection tables also varied between hospitals
Automation was observed to be related to the annual
number of biopsies. The annual number of biopsies was
8.713 (p<0.001) for units using automatic slide staining
devices, 11.584 for units with automatic mounting devices
(p<0.001), 13.415 for units with automatic cassette/slide
printers (p<0.001), and 14.261 for units with automatic
immune staining devices (p<0.001) (Table V).
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|Table V: Distribution of devices used with automation purpose according to number of biopsies
In addition to routine examinations, there was also a relation
between the annual number of biopsies and employment
of advanced examination methods as immunofluorescence
and molecular techniques.
Regarding methods used in cytology, direct smear and
centrifuge-prepared methods did not differ among
hospitals, but the use of cytocentrifugation, cell blocks
and liquid based methods did (p<0.01, p<0.01, p<0.01,
respectively). Cytocentrifugation method was used in
almost all hospitals, while cell blocks were preferred in UH
and TH. Liquid based methods were used more commonly
in UH and PH. The use of cytocentrifuge devices also
seemed to be related to the number of biopsies (p<0.001).
Autopsy procedures were more frequent in training
hospitals (p<0.01) but it was remarkable that many hospitals
did not have autopsy rooms.
When the variability between hospitals was evaluated with
respect to archiving, there was no difference in the storage
time of sample fixed tissues (p=0.536), but differences in
storage time of reports, blocks and preparations were
observed (p=0.006, p<0.001, p<0.001, respectively). The
shortest time for the storage of reports was 10 years in UH,
5 years in PH and TH, and 2 years in SH. No significant
difference was found between TH, SH and PH in the storage time of the reports. Nonetheless, it was observed that storage
times were longer in UH compared to other units. The
shortest time for the storage of blocks was 10 years in UH, 5
years in TH and PH, and 3 years in SH. The storage time in
SH was statistically significantly shorter compared to other
units. The shortest time for the storage of preparations
was 10 years in UH, 3 years in SH and PH, and 5 years in
TH. The longest time for the storage of reports, blocks and
preparations was ‘continuous' for all units. The storage time
of sampled and fixed tissues was stated to be 10-15 days.
Out of the 265 units which responded to the survey, reports had never been discarded since establishment in 166 units
(62.6%), were stored for less than 20 years in 85 (32.1%), and
stored for 20 years or longer in 14 (5.3%); blocks had never
been discarded since establishment in 125 units (47.2%),
were stored for less than 20 years in 127 (47.9%), and stored
for 20 years or longer in 13 (4.9%); slides had never been
discarded since establishment in 131 units (49.1%), were
stored for less than 10 years in 27 (10.1%), and stored for 10
years or longer in 109 (40.1%). Out of the 228 units which
responded, sampled fixed tissues were stored for less than 1
month in 39 units (17.1%).
Distinctive differences were revealed between the hospitals
when we analyzed the numbers for immunohistochemistry
and immunofluorescence staining (Table VI). The
numbers for histochemical staining were distinctively
greater in UH and TH compared to SH and PH (p<0.01).
The numbers for immunohistochemical staining was
observed to be significantly smaller or greater in UH
compared to TH (p<0.01). Furthermore, the number of
immunohistochemical stainings performed in UH and in
TH were greater than that of SH and PH (p<0.01). The
number of immunofluorescence stainings was greater in
UH compared to other hospitals (p<0.01).
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|Table VI: Distribution of annual number of histochemical, immunohistochemical, and immunofluorescence stainings used to
assist to diagnosis by hospital
Use of histochemistry and immunohistochemistry that help
the diagnosis was observed to be related to the number of
biopsies. In units where the number of biopsies was <10.000
annually, the numbers for both methods (respectively 1.143
and 464 per year) was relatively smaller. When the number
of biopsies increased to more than 10.000, the annual
number increased remarkably (Table VII).
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|Table VII: Distribution of histochemical and
immunohistochemical applications according to number of
Evaluation of the sizes of departments such as laboratories,
laboratory sub-divisions, offices, study and archive areas,
and meeting rooms showed that all areas varied among
hospitals. The total area differed between 8 and 908 m2
(101,1±114,9 m2) in the 274 units which responded to the
survey. The total area of the laboratory was smaller than 50
m2 in 94 units and 4 of these were UH, 3 were TH, 72 were
SH and 15 were PH.
If we examine these areas individually, secretarial areas
were larger in UH than TH (p=0.001), and in UH and TH
compared to other hospitals (p<0.001, p=0.015).
Routine laboratory areas did not differ between UH and
TH, but seemed to be distinctively larger in UH and EH
compared to SH and PH (p<0.001).
Macroscopy and microscopy room areas were larger in UH
compared to other hospitals including TH (p<0.001). These areas were larger in TH compared to SH and PH (p=0.001
and p<0.001). Macroscopy and microscopy room areas did
not differ between SH and PH.
The situation for the macroscopy and microscopy rooms
was also valid for special staining areas (histochemistry/
immunohistochemistry). These areas were larger in UH
than TH, and in UH and TH than SH and PH (p<0.001,
p=0.002, p=0.009, respectively). There was no difference
between SH and PH.
The archive area did not differ between UH and TH, and
between SH and PH. However, it was observed to be larger
in UH and TH compared to SH and PH (p<0.001). Storage
areas were greater in UH compared to TH, SH and PH
(p=0.01, p<0.001, p<0.001, respectively), in TH compared
to SH (p=0.03). There was no difference between TH and
SH, and PH.
The area of the autopsy room was greater in UH compared
to all other hospitals (p<0.001): However, there was no
difference between the other hospitals.
The area of the meeting room was greater in UH than all
other hospitals, and in TH than SH and PH (p=0.003,
The areas of specialists' offices were greater in UH and TH
than SH and PH (p=0.005, p=0.028, p<0.001 and p<0.001,
The resting rooms for technicians were larger in UH
compared to all other hospitals (p=0.045, p<0.001, p<0.001,
respectively). In TH, resting rooms for technicians were
larger than in SH and PH (p=0.007, p=0.001, respectively).
There was no difference between SH and PH.
Regarding work flow productivity (WFP), average WFP
values were 3.9 in UH, 4.1 in TH, 2.3 in SH and 28 in PH
(p<0.01), and values in UH and TH were significantly
higher than in SH and PH. When WFP was evaluated
according to annual biopsy numbers, it was remarkable that
average WFP was 2.5 in laboratories with annual biopsies
<10.000, 4.7 in laboratories with 10.001-20.000 biopsies,
3.9 in laboratories with 20.001-30.000 biopsies and 11.3
in laboratories >30.001 biopsies (p<0.01). WFP value was
determined to be smaller in laboratories with <10.000
annual biopsies compared to laboratories with >10.000,
while not different between laboratories with 10.001-20.000
and laboratories with 20.001-30.000, and statistically higher
in laboratories with >30.001 annual biopsies compared to
Results of a survey study carried out by the Standardization
Commission of the Turkish Federation of Pathology
Societies was published previously2,5
. That survey
represented a relatively limited section. A similar survey was carried out by extending the survey content and sending
it to a greater number of institutions with the support of
Ministry of Health.
The results of this survey have shown that the working
capacity of pathology laboratories is related to the hospitals'
number of beds (p<0.01). The Ministry of Health plans and
classifies hospitals on a national scale according to their bed
capacity and the population they serve. A similar system was
tried for planning and equipping pathology laboratories.
However, the opinion of the Standardization Commission
of the Turkish Federation of Pathology Societies is such
that, a planning based on population and/or bed capacity
will not be appropriate in our country with the present
conditions. In this aspect, the strategy report created by
Standardization Commission of the Turkish Federation
of Pathology Societies6 was based on the number of
biopsies, and the Ministry of Health abandoned planning
based on the population/number of beds for pathology
In a survey covering 325 pathology laboratories from all
over the world, it was underlined that the most productive
laboratories were those with more than 20.000 annual
biopsies3. We found the numbers of annual biopsies,
cytology, frozen, blocks and slides to be distinctively greater in UH and TH than other hospitals. Of 283 laboratories
responding to the survey, it is remarkable that only 9 had
more than 20.000 annual biopsies and the annual biopsy
number was less than 10.000 in 252 laboratories. The
number of annual biopsies of almost all service hospitals
was smaller than the ideal range which is 10.001-20.000,
and the situation was also not ideal for the university and
training hospitals. It is inevitable that a low number of
annual biopsies will negatively affect training in training
The mean annual number of frozen sections in service
hospitals was 46. This means 4 a month, and less than 1 a
week. It may therefore be unnecessary to carry out frozen
examinations at service hospitals.
Block numbers per biopsies were greater in laboratories
with >30.000 biopsies per year. This situation is explained
by preparation of more samples at training hospitals3.
The number of slides per block was observed to be very high
in laboratories with 20.001-30.000 annual biopsies. When
the numbers stated by these laboratories were evaluated, it
appeared that they had written their annual consumption
The devices of the pathology laboratories seemed to be
related to number of annual biopsies. Roughly, there was
one microscope, microtome, macroscopy cabinet, tissue
processing device, tissue embedding device, and frozen
device per 5.000 annual biopsies. The presence of devices
for automation was also related to annual biopsy numbers.
The number of biopsies per automation device changed
between 8.700 and 15.000 per year. At present, tissue
processing and tissue embedding devices are accepted as
absolute musts of pathology laboratories, like microscopes.
It is possible to prepare 19 blocks per hour in the absence
of a tissue embedding device but 40 with the device3.
Manual tissue processing cause delays in the preparation of
microscopic cases for observation by 1 day, in addition to
an increase in solution consumption and loss of work power7. Thus, determination of the productivity threshold of
these devices seems to be difficult. However, there will not
be much work to be done by technicians after the cases are
prepared for microscopic evaluation in laboratories with
less than 10.000 annual biopsies3. When device costs
are also considered, it can be stated that tissue processing
devices would especially be logical for laboratories with
more than 10.000 annual biopsies. The embedding
procedure constitutes 40% of all laboratory work3. It may
be reasonable to calculate threshold values in countries
working in shifts such as the USA, but the rationality of
embedding devices can be determined according to the number of technicians in laboratories whose annual biopsy
number is small in our country. The important point here
is that manual embedding is the procedure that takes
the longest time, one must be sure that the absence of an
embedding device does not affect the reporting time.
Devices indicating automation should be considered in
a different way. Compared to manual operations, slide
printing device is faster by 24%, staining device by 50%, a
slide mounting device 3 fold, and a film mounting device
11 fold faster3. In the USA, an automatic staining device
is present in 75% and an automatic mounting device in
65% of the laboratories while these numbers are 32% and
22% in other countries3. It is reported that the majority
of laboratories in the USA employing automatic staining
devices also use automatic mounting devices3. In our
survey, the degree of automation correlated with the biopsy
number. While both automatic staining and mounting
devices were present in 56 laboratories, only staining devices
were used in 46 laboratories. It is notable that only slide
mounting devices were present in 2 laboratories. A single
technician is required for manual staining and mounting in
laboratories handling 100 cases (320 blocks, 480 slides) per
day3. When calculated according to technician salaries
in the USA, the automation of staining and mounting
procedures would pay for themselves in less than 4 years
in a laboratory where the annual number of biopsies is
greater than 20.0003. However it is notable that there are
68 with automatic staining devices and 32 with automatic
slide mounting devices among laboratories whose annual
number of biopsies are <10.000 in our country. Among
the laboratories with <20.000 biopsies annually, automatic
staining was present in 85, automatic slide mounting in 46,
cassette and slide printers in 17 and automatic immune
staining devices in 22.
The devices which should ideally be present in a pathology
laboratory and their numbers can be determined
considering the following factors:
1. In our country, there are no work shifts except for
exceptional units. All employers work during the same
period. Some of the devices are therefore used at certain
times of the day, and remain idle at other times.
2. The productivity limit of technicians and pathologists as
determined by the Standardization Commission of the
Turkish Federation of Pathology Societies are as follows:
a. 1 pathologist for 3.000-4.000 biopsies per year in
non-training units, b. 1 pathologist for 2.000 biopsies
per year in training hospitals, c. As many technicians
as pathologists, d. +1 technician in units performing
autopsy, immunohistochemistry, molecular techniques and cytology, e. +2 technicians in training hospitals, f. 1
secretary for 2 pathologists, g. 1 microscopy technician
for 3 pathologists.
3. The duration the workers should use these devices
during the day to complete the work they are responsible
4. Worker safety and environment protection.
5. Cost of purchase and maintenance of devices.
6. Pay off time for the device.
7. The time needed for manual performance of the work in
question and the required staff hours.
We believe that it is not appropriate to determine a
requirement and number for macroscopy cabinets. There
is no need for macroscopy cabinets, if there is enough and
proper air conditioning, if the formalin concentration is
under the respiration limits, and if the macroscopy room/
department is structured properly. It is also not required
if the laboratory in question can establish ideal conditions
without the need of a macroscopy cabinet purchase.
However, the purchase of macroscopy cabinet will be the
best solution if an ideal macroscopy arrangement cannot
be established due to factors such as the physical structure
of the laboratory. The required number can be determined
considering how many stations are used at the same time.
A tissue processing device should be present in each
laboratory. However, manual tissue processing can be used
if immunohistochemistry and cytology are not performed
in the laboratory and if the annual number of biopsies is
<5.000. Tissue processing devices are also not required in
laboratories working mainly on cytology and with annual
number of biopsies <3.000. In laboratories whose annual
biopsy number is <20.000, the use of carousel type tissue
processing devices is adequate. Closed system devices
should be preferred in laboratories with a higher number
A total of 120 blocks can be prepared in one hour using an
embedding device whereas only 50 blocks can be prepared
without it. A tissue embedding device should be present
in every laboratory whose annual number of biopsies is
>5.000 excluding cytology.
In a laboratory with an annual number of 10.000 biopsies,
37-40 cases, 130 blocks and 200 slides are obtained on a
daily basis. The time for printing one slide is 20 seconds.
This means that 67 minutes will be spent for slide printing
in a laboratory with this number of biopsies3. A slide
printing device should be preferred in laboratories with an
annual number of biopsies >20.000. While no information is available on duration of cassette printing, it can be said that
cassette printing devices should be preferred in laboratories
whose annual number of biopsies is >20.000 considering
that conditions are similar to slide printing.
The ideal number of microtomes is the number of
technicians who perform sectioning. If a number is needed
per biopsy, it could be 1 microtome per 3.000-4.000 biopsies
in a laboratory with annual number of biopsies <10.000. 1
microtome per 6.000-8.000 biopsies might be enough for
laboratories whose annual number of biopsies is >10.000.
A frozen device should be present in all laboratories
providing intra-operative consultation. Portable devices
are sufficient in laboratories where the intra-operative
consultation number is <300 per year. If this number is
exceeded, a higher capacity device should be used.
Staining and mounting devices pay themselves off in 4
years in laboratories where the daily case number is 100.
Consequently, staining and mounting devices should be
preferred in laboratories whose annual number of biopsies
During preparation of non-gynecological cytologies
(effusion, urine, etc.), a smear can be made from the
pellet after centrifugation of the liquid, or smears and/or
cell blocks can be prepared by cytocentrifugation of the
pellet. Considering the time spent and consequently the
technicians needed for preparation of a direct smear, and
the fact that the time spent by the pathologist to screen
these smears will be longer than for direct smears, the use
cytocentrifuge device would be appropriate in laboratories
where non-gynecologic cytology number is >1.000.
It is stated that the number of immunohistochemistries
performed is 1 per 1.5 cases3. 1 technician can
perform 7.000 immunohistochemical stainings per
year. Automation becomes productive when annual
immunohistochemistry number is >15.000. In other words,
an immunohistochemistry staining device should be present
in laboratories where the annual biopsy number is >20.000.
It is redundant in laboratories whose annual number of
biopsies is <10.000. In laboratories where the annual biopsy
number is 10.000-20.000, it would be appropriate to decide
according to the number of technicians and the other
requirements of the laboratory.
The ideal is 1 microscope per pathologist in non-training
hospital laboratories thought to work productively.
Microscopes can be shared with good planning in
training hospitals since the pathologist will have duties
other than routine work and the number of microscopes
in laboratories might be 1/2 - 2/3 per pathologist in laboratories with more than 20.000 biopsies per year (i.e.
more than 10 pathologists). Nonetheless, here the ideal
case is again 1 microscope per pathologist. To re-define
according to the number of biopsies, 0.5-1 microscope per
2.000 biopsies in TH, and 1 microscope per 4.000 biopsies
in other hospitals is required. A polarized light attachment
should be present in the same number as the number of
rooms with microscopes.
We feel that immunofluorescence staining should be
limited to training institutions. An immunofluorescence
microscope should be present in all laboratories performing
It is sufficient for electron microscopes to be present as 1
hospital in each geographical region, provided that it is in
one of the university hospitals. Other hospitals may buy
service from here.
While 2 technicians need to work for 26 hours for 110
immunohistochemical stainings in a pathology laboratory,
the procedure takes 1 technician and 11 working
hours with an automatic staining device3. Repetitive
immunohistochemical staining constitutes the highest
expenditure in a pathology laboratory8,9. It is required
to consider the cost, as well as the effect of automation
on procedure time, while searching for a threshold value
for automation of immunohistochemical staining. Values
of 10-50$ are given in the literature for the cost of one
immunohistochemical staining8,9. Preparation of
solutions in the laboratory instead of using ready-touse
solutions achieves great savings8. In the USA, 1
immunohistochemical staining is performed per 1.5 cases3. It is notable that this number is a little bit higher in Turkey.
While it is not often used in hospitals where the annual
number of biopsies is less than 10.000, it rises to roughly
1 per 1 case in units where the annual number of biopsies
is between 10.000 and 20.000 and to 1.2 per 1 case in units
where the annual number of biopsies is greater than 20.000.
The reasons for the increase in these numbers are beyond
the scope of this article. Using quality control precautions
before the automation will give better results for standard
and high-quality immunohistochemical staining10.
We believe that if automation of immunohistochemistry
is in question in a pathology laboratory in our country,
whether the annual immunohistochemistry number is
optimal should be evaluated in addition to the number of
technicians required and time and cost calculations stated
Histochemical staining is gradually used less frequently
throughout the world. It is stated that 1 histochemical
staining is performed per 4 cases3. According to the results of our survey, the situation seems different in our
country, and the number per case can be up to 1. Automation
of histochemical staining is preferred less in our country as
well but whether the application is optimal for the laboratory
should be evaluated as for immunohistochemistry.
Immunofluorescence staining is used more often in training
hospitals, as expected. Immunofluorescence staining was
performed in 23 of UH (70%), 14 of TH (36%), and 2 of
PH (5.5%). The application rate also seems to be related to
the number of biopsies. The numbers might be considered
to be at levels that meet the needs of our country; however,
the distribution of the performing hospitals should also be
studied. It was used in 7 centers in Ankara, 6 in İzmir, 5 in
İstanbul, and 2 in Adana. The others can be stated to display
a distribution that will serve the whole country (4 in the
Central Anatolia Region, 2 in the Marmara Region, 2 in
the Aegean Region, 2 in the Eastern Anatolia Region, 2 in
the Southeastern Anatolia Region, 1 in the Mediterranean
Region and 1 in the Black Sea Region).
Among cytological preparation methods, the use of
cytocentrifugation, cell blocks and liquid-based methods
was shown to be related both to hospitals and biopsy
numbers. It can be stated that cytocentrifugation and cell
blocks are required methods for proper and sufficient
diagnosis. Liquid-based techniques were employed in 10
UH (30%), 2 TH (5%), 15 SH (8.5%) and 41 PH (27%) and
the high rates of usage were notable. The inclusion of this
method in the 2010 Budget List as a different and higherpriced
procedure might have resulted in its becoming
There is no archive regulation for pathology in our country.
There are different regulations that can be used for the
subject, and this results in confusion1. This confusion can
be clearly observed in the survey results. Archive periods
were defined to be 20 years for blocks, 10 years for slides, 20
years for reports and indefinite for electronic records in the
Private Hospitals Quality Standards Guide of the Ministry
of Health11. The formalization of these periods will be
ensured by their inclusion in the updated new version of
the clinical laboratory regulations. When these periods are
accepted as threshold values, it is remarkable that they are
not obeyed by 32.1% of units for reports, 47.9% for blocks,
10.1% for slides and 17.1% for sampled fixed tissues. It is
known that many laboratories have problems in terms of
archiving because of a shortage of space. Lack of staff and
inability to cool of block archives in warm cities are also
thought to be reasons for not attaching proper importance
The data on setting standards for pathology laboratories
is inadequate in the literature. The European Society of
Pathology suggests a total area of 321 m2 for hospital
pathology laboratories whose annual number of biopsies is
15.000-20.000, including 41.5 m2 general laboratory area,
13 m2 histopathology area, 38.5 m2 macroscopy, tissue
follow-up and archive area, 23.5 m2 cytology area, 26.5 m2
cytology screening area, 22.5 m2 laboratory offices, 34.5
m2 medical offices, 8 m2 secretariat area, 13 m2 chemical
storage area, 15 m2 archive area, 85 m2 employee rooms and
additional areas12. These area suggestions do not seem
to be appropriate for our country because of differences in
working conditions and areas. Considering that there are no
cytology scanners and fine-needle aspiration applications,
this area should be decreased to at least 260 m2. These
numbers are not logical for laboratories whose biopsy
numbers, working conditions, and areas are different. Thus,
the Standardization Commission of the Turkish Federation
of Pathology Societies has calculated that a basic pathology
laboratory should be at least 50 m2 in size, considering
devices used and excluding the office areas. According to
the survey results, there usually seems to be no problem
regarding areas in UH and TH. All areas are smaller in PH
and SH compared to UH and TH. However, it is notable that
studies are carried out in areas less than the minimum 50m2
area that we have determined in 94 (34%) of 274 laboratories
which responded to the survey. Of these 94 laboratories, 72
(77%) are SH and 15 (16%) are PH. Quality in pathology
has been taken more seriously and emphasized in recent
years, and studies on the subject have increased especially
after the Turkish Federation of Pathology Soceties was
founded. The Ministry of Health has started to set standards
on quality control, too. These studies, continuing on several
fronts, will elevate pathology laboratories that have been
ignored by hospital administrations until the recent past to
the level they deserve.
The threshold value for work flow productivity is stated
to be 43. It is specified that the laboratories whose work
flow productivity value is smaller than 4 are unproductive
and that the reasons lowering this value could be excess
personnel, unproductive performances in some procedures
or both these reasons, and the reason should be identified
and resolved3. In our country, it is notable that WFP
values are at the threshold in UH and TH, and that PH
and SH and in general hospitals with an annual number
of biopsies <10.000 work unproductively. Productivity is
observed to increase with increasing annual number of
biopsies. Device automation accompanying increasing
biopsy numbers can be said to play a role as important as
the number of staff.
In conclusion, we think that all pathology laboratories
in our country should evaluate and improve their own
productivity. Improvements in physical conditions should
be ensured, with the support of administration, in a large
number of laboratories. Pathology-specific archiving
periods need to be formalized. Otherwise, our colleagues
may have problems with possible future malpractice suits.
Turkish Federation of Pathology Societies has a lot of
work to do on all these matters. Informative meetings on
related subjects must be arranged, and finding a solution to
problems with the relevant legal and administrative units
must be targeted. As many colleagues as possible should
provide support and contribution during this period.
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