Volume 35 Number 4 | August 2021

Patient Safety Corner

Shannon Jongeward, MS, MLS(ASCP)CM

Shannon Jongeward“Do more with less.” This adage becomes more and more relevant in the clinical laboratory as the climate of healthcare continues to change. Value-based reimbursement systems are replacing the traditional fee-for-service system. Under these new systems, reimbursement for healthcare services is tied to the quality of care, or positive patient outcome. In order for laboratories to endure in this new climate, they must continue to improve quality and ensure patient safety, all while cutting costs.

According to a report by the Organization for Economic Co-operation and Development (OECD), the most common reason for medical negligence claims in primary and ambulatory settings is diagnostic errors.1 The report estimated that approximately 12 million U.S. adults will be victims of diagnostic error, and up to half of those will suffer severe consequences as a result. One way for labs to endure in the new reimbursement systems and ensure patient safety is to consider implementing laboratory stewardship programs.

Laboratory stewardship programs help ensure that proper tests are ordered, that the retrieval and interpretation of laboratory results is accurate, and that financial responsibility is maintained.2 Test utilization management strategies have been used by many laboratories to cut costs. These strategies focus on the right patient, with the right test, at the right time. Laboratory stewardship programs use test utilization strategies and add a quality component that focuses on the value of the service relative to its cost.3

Modeled after antibiotic stewardship programs, laboratory stewardship programs include four components: Governance, Interventions, Data Extraction & Monitoring, and Continual Assessment/Improvement.3

  • A commitment from leadership is needed to assure the necessary resources are available, including human and financial resources. This is absolutely crucial.
  • A physician/doctoral-level leader should be identified as responsible for program outcomes.
  • Committees and subcommittees should be formed that focus on particular topics, programs, or process issues in the healthcare system.
  • Laboratory leadership and other institutional support areas should be involved, including clinicians, finance, quality improvement, and information technology staff.
  • Networking with other groups such as the American Association for Clinical Chemistry, College of American Pathologists, and even reference laboratories is important as these groups promote stewardship programs and may offer peer comparison data that may be useful in identifying test utilization problem areas.

Interventions are the process changes laboratories make to improve laboratory test utilization. There are three categories of interventions: Gentle, Medium, and Strong.

  • Gentle interventions do not require systematic changes; instead, they are more educational in scope. Providing training or lectures to non-laboratory staff is one example of a gentle intervention.
  • Medium interventions involve systematic changes; however, they still allow providers some flexibility to make decisions. Hiding a test option in computerized provider order entry (CPOE) but allowing the test to be ordered if specifically requested is one example of a medium intervention.
  • Strong interventions eliminate unnecessary and/or unintended testing. Implementing hard stops in CPOE that completely prevent providers from ordering a specific test under certain criteria (i.e., a duplicate order) is an example of a strong intervention.
Data Extraction and Monitoring

This element focuses on the appropriateness of the ordered test, appropriateness of the test interpretation, retrieval of test results, and impact the stewardship program is having on the healthcare facility. Providing data on the ordering patterns of providers is important to gain their confidence in the changes that are made and to encourage them to change their ordering habits.

Continual Assessment/Improvement

This element includes both the assessment and prioritization of potential stewardship opportunities as well as identifying opportunities for improvement within the program itself. To prioritize potential stewardship opportunities, criteria should be identified ahead of time and reflect the institution’s priorities. Initiatives that focus on improving the stewardship program should also be prioritized based on selected stewardship opportunities and available resources. Continually assessing for stewardship opportunities and areas for program improvement provides a proactive approach. Members of the stewardship program and its committees and subcommittees should perform these tasks.

Within healthcare, stewardship means managing overall institutional resources responsibly. Laboratories play a very important role in optimizing value-based care and ensuring the responsible use of resources. Thus, it is important for laboratories to identify areas for improvement relating to their overall impact to the institution.

Easy First Steps

You may think that implementing such a program at your institution is unrealistic. Perhaps you have neither the personnel to take on such a task, nor the time or financial resources required. There are easy interventions that can be taken that require minimal effort.

  1. Offer educational sessions to providers and nursing staff. Utilize these sessions to present updates on laboratory test or methodology changes happening in the lab and to discuss emerging or newly developed diagnostic tests and their appropriate use.
  2. Look at your test menu. Are there tests that are obsolete that should be removed?
  3. Assess your test nomenclature. Ensure the names of your tests make it easy for providers to select the right test.
  4. If you use paper requisitions, make sure they are formatted for optimal test ordering and include ordering guidelines.
  5. If possible, utilize the computerized provider order entry (CPOE) in your facility. Create order alerts that provide additional information that might help with test selection, such as a description of the test or a notification that the test may potentially be a duplicate (i.e., a different provider ordered the same test only a few hours prior).
  6. Also, provide laboratory test cost information or price alerts. This information may be especially helpful to prevent tests being ordered to “cover the bases.”

Laboratory stewardship programs can help facilities standardize their practices to improve patient care and decrease costs. Laboratory leaders, providers, and payers, all have a common ground to utilize laboratory testing in the most cost-effective way that benefits the healthcare system and patients.

  1. Auraaen A, Slawomirski L, Klazinga N. The economics of patient safety in primary and ambulatory care: Flying blind. Organization for Economic Cooperation and Development Health Working Papers No. 106. 2018 Nov 27. https://www.oecd.org/els/health-systems/health-working-papers.htm
  2. Astion M, Dickerson J. Laboratory Stewardship focus: A new quarterly section in Clinical Laboratory News. Clin Lab News. 2019 Jan/Feb;45(1): 30-1.
  3. Dickerson JA, Fletcher AH, Procop G, Keren DF, Singh IR Garcia JJ, et al. Transforming laboratory utilization review into laboratory stewardship: Guidelines by the PLUGS National Committee for Laboratory Stewardship. J Appl Lab Med. 2017 Sept 1;2(2):259-68. doi: 10.1373/jalm.2017.023606.

Shannon Jongeward is an Assistant Professor of Medical Laboratory Science at the University of North Dakota and has been serving on the ASCLS Patient Safety Committee for a number of years.