Dermatology

Requires Standards 1–7 verified first

4 criteria

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [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.

A missed or delayed biopsy result carries a specific, serious risk in dermatology that general test-result tracking may not fully capture — a missed melanoma diagnosis is a genuine, well-documented, sometimes fatal failure mode, and biopsy tracking deserves its own dedicated, higher-vigilance process, not just inclusion in a general results system.

1 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.

2 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.

3 Results are tracked internally but patient communication specifically isn't logged.

An internally reviewed result that never reaches the patient still represents the failure this criterion exists to prevent.

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.

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.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [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.

Cryotherapy and similar in-office procedures carry real risk of under-treatment, missing a lesion that needed more aggressive management, or over-treatment causing unnecessary scarring or damage — a defined protocol matched to lesion type is what keeps this risk genuinely managed rather than left to individual judgement alone.

1 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.

2 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.

3 Post-procedure instruction is given verbally but not consistently provided in writing.

Written instruction the patient can refer back to is more reliable than a verbal explanation alone.

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.

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.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [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.

Phototherapy dosing that isn't grounded in a defined protocol risks either under-dosing, reducing treatment effectiveness, or over-dosing, causing burns or unnecessarily high cumulative UV exposure — the evidence specifically defines how dose should adjust based on the patient's own erythema response, not general estimation.

1 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.

2 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.

3 The protocol is followed for standard cases but less consistently for patients on photosensitising medications.

Certain medications meaningfully change UV risk, and dosing decisions should reflect this.

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.

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.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [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.

The time between identifying a suspicious lesion and taking definitive action is a genuine, modifiable factor in outcome, particularly for melanoma — a defined, timed pathway removes the risk of a suspicious finding quietly losing urgency as it moves through scheduling and follow-up.

1 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.

2 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.

3 Tracking exists but isn't reviewed for patterns of delay.

Untracked or unreviewed data doesn't reveal whether the timeframe is genuinely being achieved.

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.

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.