ASF Standards · Ambulatory Clinic · Standard 17
Standard 17 — Dermatology
Criteria in this standard
17.1 — Biopsy Specimens Are Tracked to a Confirmed Pathology Result
17.2 — Cryotherapy and In-Office Procedures Follow a Defined Safety Protocol
17.3 — Phototherapy Dosing Follows Evidence-Based Protocol, Not Estimation
17.4 — Suspicious Lesions Have a Defined, Timed Escalation Path
17.2 — Cryotherapy and In-Office Procedures Follow a Defined Safety Protocol
17.3 — Phototherapy Dosing Follows Evidence-Based Protocol, Not Estimation
17.4 — Suspicious Lesions Have a Defined, Timed Escalation Path
17.1
Biopsy Specimens Are Tracked to a Confirmed Pathology Result
Non-Negotiable
Every skin biopsy is tracked from collection through to a confirmed, communicated pathology result, with a specific, named process ensuring no specimen result goes unreviewed or unreported to the patient — distinct from, and more specifically tracked than, general test results.
In plain terms: Every skin biopsy is tracked from the moment it is taken until the pathology result is reviewed and the patient told — a named person makes sure none is lost.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | N/A | Full | Full | Full |
Why this matters
A melanoma biopsy that is lost, or whose result sits unread, or whose result is read but the patient is never contacted, is a death sentence delivered by administrative failure. Dermatology practices take many biopsies; most are benign; the system relaxes; and the one malignant result that matters is the one that slips through. Tracking means a log — specimen taken, sent, result received, reviewed, patient informed — with dates at each stage, checked weekly for gaps, and owned by a named person. Every entry must reach 'patient informed' or the log flags it.
What good looks like
- A specific, dedicated biopsy tracking process exists, distinct from general results.
- The system can identify and surface a specimen whose result was never received.
- Patient communication of the result is itself tracked, not assumed.
Common failure modes
- Biopsies are tracked only within a general test-result system, with no distinct process.
- There is no way to identify a specimen that fell through the cracks.
- Communication to the patient is assumed but not actually tracked.
Worked example
In practice
A dermatology clinic taking 60 biopsies a month.
BeforeSpecimens were sent to the lab with a request form. Results came back by post and were filed in the patient's notes for review at the next appointment. No log existed. When the Coordinator reviewed three months of lab records against patient notes, four results had never been reviewed — one was a melanoma, now four months old.
ActionA biopsy log was created: date taken, patient, site, date sent, expected result date, date received, date reviewed by clinician, date patient informed, action. The practice nurse owns it and checks it weekly. Any result not received within 14 days is chased. Any result not reviewed within 48 hours of receipt is escalated. Any patient not informed within 7 days of review is called. Malignant results trigger same-day patient contact.
AfterThe Monitor reviewed the log for three months: 180 biopsies, all reaching 'patient informed'; median time from result to patient contact 3 days; two melanomas identified and referred within 24 hours. Verified.
If you are starting from zero — do this first
- Get your lab's list of specimens received from you last month. Match each to a reviewed result in your records.
- Start a biopsy log with all stages and dates.
- Name one person to own it and check weekly.
- Set a rule: malignant results → patient contacted same day.
The most common mistake: Filing results for review at the next appointment — the melanoma patient may not have one booked.
Self-assessment questions
1. Is there a specific, named tracking process for biopsy specimens, distinct from general test result tracking? — A dedicated process specifically for biopsies, given the distinct severity risk.
Evidence: Biopsy tracking log
Evidence: Biopsy tracking log
2. Is there a way to identify a biopsy specimen whose result was never actually received or reviewed? — An active mechanism that surfaces a gap, not one that only shows completed results.
Evidence: Uncollected result identification process
Evidence: Uncollected result identification process
3. Is the confirmed result specifically communicated to the patient, with the communication itself tracked? — Tracked communication, not an assumption the patient was informed because the result exists in the chart.
Evidence: Patient communication tracking record
Evidence: Patient communication tracking record
Common reasons for a PARTIAL answer
- Tracking exists for biopsies taken by the primary dermatologist but not consistently for those taken by covering staff. — Every biopsy carries the same real risk, regardless of who performed it.
- The tracking log exists but isn't reviewed on a regular schedule to catch gaps. — A log that isn't actively reviewed provides limited real protection against a missed result.
- Results are tracked internally but patient communication specifically isn't logged.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current biopsy tracking practice for a specific, dedicated process. |
| Week 2 | Establish a tracking log covering every biopsy from collection to confirmed, communicated result. |
| Week 3 | Build a mechanism to actively surface any specimen without a received result. |
| Ongoing | Review the tracking log on a regular schedule for gaps. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Biopsy tracking log review | Reviews the specific biopsy tracking log for completeness from collection to confirmed result. |
| OBSERVE | Uncollected result identification check | Checks whether the tracking system can actually surface a specimen whose result was never received. |
| DOCUMENT | Patient communication tracking review | Reviews evidence that result communication to the patient is itself tracked, not assumed. |
Supervisor tips
- Ask for the actual tracking log and pick a specific, older biopsy to trace through it. — Tracing a real, specific case reveals whether the system genuinely works, not just whether it exists.
- Ask specifically about biopsies taken by staff other than the primary dermatologist. — This is where tracking most commonly shows real gaps.
Evidence base
[79] Failure to track biopsy specimens to a confirmed, communicated result is identified as a specific and serious contributor to delayed melanoma diagnosis in dermatology patient safety literature, distinct in severity from general diagnostic test follow-up.
Train your team: AMB-17 · Dermatology on GMJ Academy →
This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.
17.2
Cryotherapy and In-Office Procedures Follow a Defined Safety Protocol
Non-Negotiable
Cryotherapy and other in-office dermatological procedures follow a defined protocol for technique, treatment depth appropriate to the lesion, and post-procedure care instruction — not applied based on individual practitioner habit without a documented, consistent standard.
In plain terms: Cryotherapy, curettage, and other in-office skin procedures follow a written protocol for technique, depth, and aftercare — not each clinician's personal habit.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | N/A | Full | Full | Full |
Why this matters
Cryotherapy applied too long causes scarring, nerve damage, and depigmentation; applied too briefly it fails and the lesion — which may be malignant — recurs. Curettage without a defined margin leaves tumour behind. Aftercare instructions that vary by clinician confuse patients and cause infections. A protocol per procedure states the technique, the freeze time and cycles by lesion type, the margin, the aftercare, and when to review. It makes outcomes consistent and auditable. 'I've been doing it this way for years' is not a protocol.
What good looks like
- A defined, documented protocol governs technique and treatment depth.
- Lesion suitability for cryotherapy versus biopsy is genuinely assessed before treatment.
- Post-procedure instruction is consistent and procedure-specific.
Common failure modes
- Technique and depth vary by individual practitioner without a documented standard.
- Suspicious lesions are treated without a genuine biopsy-versus-treatment decision.
- Post-procedure instruction is generic or inconsistently given.
Worked example
In practice
A dermatology clinic with three clinicians performing cryotherapy and curettage.
BeforeEach clinician had their own approach. Freeze times were by feel. Aftercare instructions were verbal and inconsistent. A patient developed a large hypopigmented scar on the face after prolonged cryotherapy for a seborrhoeic keratosis. Another had a basal cell carcinoma recur after curettage with no defined margin.
ActionProtocols were written for the five most common in-office procedures, based on national dermatology guidance: indications, contraindications, technique, freeze time and cycle count by lesion type and site, margin for curettage, written aftercare instructions, and review timing. All clinicians agreed to follow them. A quarterly audit of ten procedures checks compliance and outcome.
AfterThe Monitor reviewed the protocols, the aftercare sheets, and two quarterly audits showing compliance and no scarring complaints in the period. Verified.
If you are starting from zero — do this first
- Ask each clinician how long they freeze a plantar wart. If the answers differ, that is the gap.
- Write a protocol per common procedure with freeze times by lesion and site.
- Standardise written aftercare.
- Audit ten procedures a quarter.
The most common mistake: Treating cryotherapy as trivial — it is a destructive procedure with permanent consequences when done wrong.
Self-assessment questions
1. Does the practice follow a defined protocol for technique and treatment depth matched to lesion type? — A specific, documented protocol, not individual practitioner habit alone.
Evidence: Procedure protocol document
Evidence: Procedure protocol document
2. Is there a documented process for confirming a lesion's suitability for cryotherapy before treating, rather than a suspicious lesion being frozen without biopsy consideration? — A specific decision point, not automatic treatment without considering whether biopsy is warranted first.
Evidence: Lesion suitability assessment record
Evidence: Lesion suitability assessment record
3. Is post-procedure care instruction given consistently, specific to the procedure performed? — Consistent, procedure-specific instruction, not generic aftercare advice.
Evidence: Post-procedure instruction documentation
Evidence: Post-procedure instruction documentation
Common reasons for a PARTIAL answer
- The protocol is followed by the primary dermatologist but not consistently by covering or newer staff. — Consistency needs to extend to everyone performing the procedure, not only the most experienced practitioner.
- Lesion suitability assessment happens for obviously ambiguous cases but not routinely for all lesions. — The decision to treat rather than biopsy deserves genuine consideration for every lesion, not only the visually ambiguous ones.
- Post-procedure instruction is given verbally but not consistently provided in writing.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current technique and depth practice for consistency against a defined protocol. |
| Week 2 | Establish or reinforce a genuine lesion-suitability assessment step before treatment. |
| Week 3 | Standardise written post-procedure instruction specific to each procedure type. |
| Ongoing | Audit protocol consistency across all practitioners performing procedures. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Protocol review | Reviews the defined technique and depth protocol against actual practice. |
| OBSERVE | Lesion suitability assessment observation | Observes whether lesion suitability for cryotherapy versus biopsy is genuinely assessed before treatment. |
| DOCUMENT | Post-procedure instruction review | Reviews post-procedure care documentation for consistency and procedure specificity. |
Supervisor tips
- Ask a practitioner to describe their decision process for a specific, recent case. — Specificity reveals whether a genuine, consistent protocol is followed, not individual habit.
- Ask what would prompt biopsy instead of direct treatment for an ambiguous lesion. — A confident, specific answer reveals genuine, consistent clinical judgement embedded in practice.
Evidence base
[80] Defined, lesion-appropriate technique and depth protocols for cryotherapy and similar in-office dermatological procedures are established practice for balancing treatment efficacy against the risk of under- or over-treatment.
Train your team: AMB-17 · Dermatology on GMJ Academy →
This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.
17.3
Phototherapy Dosing Follows Evidence-Based Protocol, Not Estimation
Non-Negotiable
UV phototherapy dosing is based on minimal erythema dose testing or a defined skin-phototype protocol, with dose adjustment following specific, evidence-based rules based on erythema response — not estimated by practitioner judgement without a documented dosing framework.
In plain terms: UV phototherapy doses start from a measured or skin-type-based baseline and increase according to written rules based on the patient's skin response — not by guesswork.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | N/A | Full | Full | Full |
Why this matters
Phototherapy is a controlled burn. Too much UV causes painful erythema, blistering, and — cumulatively — skin cancer. Too little wastes the patient's time and delays treatment. The starting dose must be individualised: either a minimal erythema dose test or a validated skin-phototype schedule. Each subsequent dose depends on the response to the last: no erythema → increase by a defined percentage; mild → hold; painful → reduce or skip. Cumulative dose is tracked against lifetime limits. A unit that increases 'by feel' will burn some patients and undertreat others.
What good looks like
- Initial dose is based on minimal erythema dose testing or a defined skin-phototype protocol.
- Dose adjustment follows specific, evidence-based rules tied to erythema response.
- Cumulative UV exposure is tracked over the full course of treatment.
Common failure modes
- Initial dose is estimated without a defined protocol.
- Dose adjustment is based on general practitioner judgement without specific rules.
- Cumulative exposure isn't tracked beyond individual session records.
Worked example
In practice
A dermatology clinic with a narrowband UVB cabinet treating 40 patients.
BeforeStarting doses were chosen by the nurse's impression of skin type. Increases were 'about 20% if it looked OK.' Erythema was not systematically recorded. Cumulative doses were not tracked. Three patients had been burned in the previous year; one was a skin type II patient started on a type IV dose.
ActionA phototherapy protocol was adopted from national guidance: MED testing for all new patients, or skin-phototype starting dose where MED testing is impractical; an erythema score recorded before each treatment; dose adjustment rules by score (0 → +20%, 1 → +10%, 2 → hold, 3+ → reduce and review); cumulative dose logged and reviewed at 200 treatments. Cabinet output is measured quarterly.
AfterThe Monitor reviewed 20 patient phototherapy records with MED or phototype baselines, erythema scores at each visit, rule-based adjustments, and cumulative doses. Cabinet calibration certificate on file. No burns in six months. Verified.
If you are starting from zero — do this first
- Pull ten phototherapy records: is the starting dose justified? Is erythema scored each visit?
- Adopt a national phototherapy protocol with adjustment rules.
- Start MED testing or use a validated phototype schedule.
- Track cumulative dose and calibrate the cabinet quarterly.
The most common mistake: Increasing the dose by a fixed amount each visit regardless of the patient's response.
Self-assessment questions
1. Is initial phototherapy dose based on minimal erythema dose testing or a defined skin-phototype protocol? — A specific, evidence-based starting point, not an estimated or arbitrary initial dose.
Evidence: Initial dosing protocol document
Evidence: Initial dosing protocol document
2. Does dose adjustment follow specific, defined rules based on the patient's actual erythema response? — A specific rule set, not practitioner judgement applied inconsistently.
Evidence: Dose adjustment protocol
Evidence: Dose adjustment protocol
3. Is cumulative UV exposure tracked over the course of treatment, not just each session's dose in isolation? — Tracked cumulative exposure, since total lifetime UV exposure carries its own real, distinct risk.
Evidence: Cumulative exposure tracking record
Evidence: Cumulative exposure tracking record
Common reasons for a PARTIAL answer
- Initial dosing follows the protocol but adjustment decisions become less rule-based as treatment continues. — Adjustment discipline matters throughout the full course, not only at initiation.
- Dosing records exist per session but aren't summed to show cumulative exposure. — Individual session records don't reveal the cumulative exposure picture that carries its own distinct risk.
- The protocol is followed for standard cases but less consistently for patients on photosensitising medications.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current dosing practice against minimal erythema dose or skin-phototype protocol standards. |
| Week 2 | Establish specific, documented dose adjustment rules based on erythema response. |
| Week 3 | Build cumulative UV exposure tracking into the treatment record. |
| Ongoing | Audit dosing decisions against the defined protocol periodically. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Initial dosing protocol review | Reviews initial dosing practice against minimal erythema dose or skin-phototype protocol standards. |
| DOCUMENT | Dose adjustment record review | Reviews dose adjustment records against specific, evidence-based erythema response rules. |
| DOCUMENT | Cumulative exposure tracking review | Reviews whether cumulative UV exposure is tracked over the full course of treatment. |
Supervisor tips
- Ask for the specific dose adjustment rule used for a documented erythema response. — A specific, correct answer reveals genuine protocol-based practice, not general estimation.
- Ask to see cumulative exposure tracking for a patient partway through a treatment course. — This reveals whether cumulative risk is genuinely tracked, not just individual sessions.
Evidence base
[81] Established dermatology guidelines of care for the management and treatment of psoriasis with phototherapy establish minimal erythema dose or skin-phototype-based initial dosing, with specific dose adjustment rules based on erythema duration following treatment.
Train your team: AMB-17 · Dermatology on GMJ Academy →
This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.
17.4
Suspicious Lesions Have a Defined, Timed Escalation Path
Non-Negotiable
A lesion with suspicious features has a defined, timed escalation path — biopsy timeframe, referral pathway for advanced management — verified as actually followed, not left to case-by-case urgency judgement without a specific standard.
In plain terms: A lesion that looks suspicious has a fixed path — biopsy within a set time, referral to a specialist if needed — that is followed, not decided case by case.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | N/A | Full | Full | Full |
Why this matters
A melanoma thickens by a fraction of a millimetre a week, and thickness determines survival. A suspicious lesion that waits three weeks for a biopsy appointment, then two weeks for a result, then a month for a referral, has been given ten weeks to grow. A defined pathway sets clocks: suspicious lesion identified → biopsy within 7 days → result reviewed within 48 hours → if malignant, referral sent within 24 hours and confirmed received. The pathway is written, everyone knows it, and it is audited. Urgency should not depend on which clinician saw the patient or how busy the day was.
What good looks like
- A specific, defined timeframe governs suspicious lesion biopsy.
- A specific, named referral pathway exists for advanced management.
- Adherence to the timeframe is actively tracked, not assumed.
Common failure modes
- Suspicious lesions are scheduled through routine, non-expedited booking.
- No specific referral pathway exists beyond general intention.
- No tracking exists to confirm the defined timeframe is actually being met.
Worked example
In practice
A dermatology clinic with a two-to-three-week wait for biopsy appointments.
BeforeSuspicious lesions were booked into the next available biopsy slot. Results were reviewed at the patient's next appointment. Referrals to the melanoma unit went by letter. The Coordinator traced three melanoma diagnoses from the previous year: median time from first visit to specialist referral was 52 days.
ActionA suspicious lesion pathway was written: any lesion meeting defined criteria (ABCDE, new or changing pigmented lesion, non-healing ulcer) → same-week biopsy slot (three reserved per week); result flagged urgent to the lab; reviewed within 48 hours of receipt; if malignant → same-day phone call to patient and electronic referral to the melanoma unit with phone confirmation. The pathway is audited monthly with time-to-referral tracked.
AfterThe Monitor reviewed the pathway, the reserved slot system, and six months of tracking: median first visit to referral 9 days for malignant lesions. Verified.
If you are starting from zero — do this first
- Trace your last three malignant skin diagnoses: how long from first visit to specialist referral?
- Write suspicious lesion criteria and a timed pathway.
- Reserve biopsy slots each week for urgent lesions.
- Track time-to-referral monthly.
The most common mistake: Booking a suspicious lesion into the routine biopsy queue — the routine queue is designed for lesions that can wait.
Self-assessment questions
1. Is there a specific, defined timeframe for biopsying a lesion identified as suspicious, not routine scheduling? — A specific, known timeframe, not folded into normal appointment availability.
Evidence: Escalation timeframe protocol
Evidence: Escalation timeframe protocol
2. Is there a defined referral pathway to advanced management when findings warrant it? — A specific, named pathway, not a general intention to refer if needed.
Evidence: Referral pathway document
Evidence: Referral pathway document
3. Is adherence to the escalation timeframe actually tracked, not assumed from the pathway existing on paper? — Genuine tracking of actual timeframes achieved, not an assumption the pathway is followed.
Evidence: Escalation timeframe adherence record
Evidence: Escalation timeframe adherence record
Common reasons for a PARTIAL answer
- A timeframe is defined but not consistently communicated to scheduling staff. — A defined standard that scheduling staff don't know about doesn't reliably translate into faster action.
- The referral pathway exists but hasn't been used recently, so its current functioning is unverified. — An untested pathway may not translate smoothly into real use when actually needed.
- Tracking exists but isn't reviewed for patterns of delay.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current suspicious lesion scheduling against any existing timeframe standard. |
| Week 2 | Define or reinforce a specific escalation timeframe and communicate it to scheduling staff. |
| Week 3 | Confirm the referral pathway for advanced management is current and functioning. |
| Ongoing | Track and review actual timeframe adherence for patterns. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Escalation timeframe review | Reviews the specific, defined timeframe for suspicious lesion biopsy. |
| DOCUMENT | Referral pathway review | Reviews the specific, named referral pathway for advanced management. |
| DOCUMENT | Adherence tracking review | Reviews records tracking whether the defined escalation timeframe is actually being met. |
Supervisor tips
- Ask scheduling staff specifically what happens when a lesion is flagged as suspicious. — This reveals whether the defined timeframe genuinely reaches the people responsible for scheduling.
- Ask for a real, recent example of the referral pathway being used. — A real example reveals whether the pathway genuinely functions, not just exists on paper.
Evidence base
[82] Defined, timed escalation pathways for suspicious skin lesions, distinct from routine follow-up scheduling, are established practice for minimising diagnostic delay in melanoma and other malignant skin lesions.
Train your team: AMB-17 · Dermatology on GMJ Academy →
This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.