There are multiple approaches to improve standardization of pathology reports: synoptic reporting, national guidelines, and pathologist education are all beneficial. Keeping up with new information and recommendations often falls to the individual pathologist or group, and there are different approaches to optimizing this knowledge diffusion [10, 30].

The development and circulation of formal criteria are critical steps in improving uniformity of pathology diagnoses. After a small study that involved sending slides of epithelial breast proliferations out to specialty pathologists revealed unacceptably high levels of interobserver disagreement (no case exhibited 100 % concordance) [31], a second group first distributed criteria for the diagnosis of epithelial breast proliferations and then also shared slides to determine concordance rates between six breast pathologists. They found that the addition of the first distributing criteria for diagnosis resulted in a higher concordance rate amongst the group, with complete agreement in 58 % of cases and near complete agreement in 71 % [32]. While these figures are encouraging, the nearly 30 % disagreement between experts illustrates that there is additional room for improvement.

The WHO criteria for classification of gliomas have been widely distributed. To evaluate concordance between neuropathologists using the same criteria, a group of neuropathologists gathered four times over the course of 18 months to review glioma cases together after independent review. They found that there were few discrepancies between pathologists about grade 4 tumors, but many between grades 2 and 3 that rely, at least partially, on more subjective criteria such as hypercellularity and atypia or on diligence criteria such as finding rare mitoses. However, concordance between the four pathologists did increase over the 18 months (from 54 to 86 %), revealing both that while formal criteria are informative, they will not alone result in concordance and that training through consensus and discussion can be very valuable in creating more consistent diagnoses [33].

Guideline review and discussion is not always as effective. One group investigated the reproducibility of the ASCUS diagnosis using the Bethesda manual by dividing 100 cases (negative, ASCUS, squamous intraepithelial lesion based on five-person consensus) into pre- and post-tests. Eight pathologists (four experienced cytopathologists and four with less experience) first reviewed the 50 pretest cases with absolute agreement between 44 and 62 %. Next, they broke into two teams, each with two more and two less experienced cytopathologists, and reviewed together the Bethesda manual. The absolute agreement on the post-test was 40–60 %, illustrating relatively weak reproducibility of the diagnosis of ASCUS even with added training and consensus [34].

Pathologists at the University of Oklahoma, noting historically slow adoption of new guidelines, took a more aggressive approach to guideline distribution within their department. They first distributed a pretest about the new guidelines for lung cancer reporting and molecular testing. Pathologists who scored low were required to attend a seminar about the guidelines and were assigned to a second pathologist who had scored well to review lung tumor cases. Cases that were signed out before and after this intervention were reviewed, and they found a significant increase in the application of the guidelines. The department also moved from a general to a specialized sign-out during this time, which may confound the data; however, only one of the pathologists signing out lung cases in the subspecialized system had passed the pretest. These findings suggest that taking a hands-on approach to distributing new guidelines can be effective, and the authors suggest that including self-assessment tools for use by pathologists or departments when new guidelines are released for pathology reporting may expedite compliance [35].

There are multiple approaches to improve surgical pathology standardization: synoptic reporting , national guidelines, and pathologist education. Board exams and hospital appointment regulations mandate a very basic level of competence. The continuation of pathologists’ privileges at a hospital hinges on the quality and safety of care delivered. The review of privileges falls on the medical staff, which monitors the performance of the pathologists who are granted privileges and makes recommendations regarding which medical staff members should receive new or maintain existing privileges.