Journal:Strategies for laboratory professionals to drive laboratory stewardship

Full article title	Strategies for laboratory professionals to drive laboratory stewardship
Journal	Practical Laboratory Medicine
Author(s)	White, Terra, E.; Wong, Wesley B.; Janowiak, Diane; Hilborne, Lee H.
Author affiliation(s)	Quest Diagnostics, hc1, University of California - Los Angeles
Primary contact	terra dot e dot white at questdiagnostics dot com
Year published	2021
Volume and issue	26
Article #	e00249
DOI	10.1016/j.plabm.2021.e00249
ISSN	2352-5517
Distribution license	Creative Commons Attribution 4.0 International
Website	https://www.sciencedirect.com/science/article/pii/S2352551721000494
Download	https://www.sciencedirect.com/science/article/pii/S2352551721000494/pdfft (PDF)

Abstract

Appropriate laboratory testing is critical in today's healthcare environment that aims to improve patient care while reducing cost. In recent years, laboratory stewardship has emerged as a strategy for assuring quality in laboratory medicine with the goal of providing the right test for the right patient at the right time. Implementing a laboratory stewardship program now presents a valuable opportunity for laboratory professionals to exercise leadership within health systems and to drive change toward realizing aims in healthcare. The proposed framework for program implementation includes five key elements: 1) a clear vision and organizational alignment; 2) appropriate skills for program execution and management; 3) resources to support the program; 4) incentives to motivate participation; and, 5) a plan of action that articulates program objectives and metrics. This framework builds upon principles of change management, with emphasis on engagement with clinical and administrative stakeholders and the use of clinical data as the basis for change. These strategies enable laboratory professionals to cultivate organizational support for improving laboratory use and take a leading role in providing high-quality patient care.

Keywords: clinical laboratory, laboratory stewardship, quality of health care, change management, patient care, leadership

Introduction

Establishing the correct diagnosis is fundamental to the appropriate treatment of patients, making laboratory testing and other diagnostic services (e.g., radiology) critical to the overall practice of medicine. Some suggest that up to 70% of medical decisions are based, in part, on laboratory findings. While the specific percentage may be debatable, there is no question that laboratory diagnostics are central for medical practice today. The coronavirus disease 2019 (COVID-19) pandemic highlighted the critical role that the nation's laboratories and laboratory professionals play in assuring quality healthcare, well beyond just the pandemic response. Healthcare leaders repeatedly acknowledged the importance of laboratory testing for COVID-19 patient management to, for example, assess symptomatic patients, identify emerging variants, and perform effective contact tracing. Laboratory medicine is also central to the worlds' public health response to COVID-19.

Laboratory testing is typically one of the highest volume medical activities in a health system. Despite their major role in driving clinical decision-making, laboratory diagnostics are highly variable and filled with opportunities to increase appropriate testing while reducing waste. Annual cost estimates in the U.S. for low-value screening, testing, or procedures range from $17.2 billion to $27.9 billion. Excessive diagnostic testing can also increase patient risk while not improving diagnostic certainty. Achieving the aims of higher quality and lower cost depends on the laboratory community taking a central role in improving effective test utilization.

Over the last century, pathologists and laboratory professionals honed their craft while simultaneously expanding tools available to screen, diagnose, treat, and manage patients. The laboratorian historically focused quality efforts on a test's analytic quality. While analytic quality is necessary for appropriate care, it is not sufficient; effective test utilization requires clear medical justification to support the need for a particular test with an understanding of how the results will contribute to guiding patient management. This discussion focuses on the evolution of effective test utilization and implementation of laboratory stewardship as a laboratory leadership strategy to assure effective test use.

Evolution of quality in laboratory medicine

The pursuit of laboratory medicine quality improvement will shortly celebrate its one-hundredth anniversary. In 1922, a group of 39 physicians came together to form what is now known as the American Society for Clinical Pathology (ASCP), now the largest professional organization of pathologists and laboratory professionals in the world. The goal of the ASCP was to “achieve greater scientific proficiency in clinical pathology [meaning here the practice of pathology in the clinical setting, including both anatomical and clinical pathology], and to maintain the status of clinical pathologists on an equal plane with other specialists.” ASCP recognized the contributions and importance of both quality people and quality processes to assuring reliable laboratory results. As such, ASCP was instrumental in creating the American Board of Pathology (1935) to certify pathologists and the Board of Registry (now the Board of Certification) to certify laboratory professionals (1928). ASCP, under the guidance of past president F. William Sunderman, created an inter-laboratory quality control program, now recognized as the College of American Pathologists’ Proficiency Testing Program.

The evolution of quality in pathology and laboratory medicine paralleled that of medicine generally. In 1910, Abraham Flexner issued his landmark report that fundamentally restructured medical education in the U.S., a structure still used today. Training moved from a relatively unstructured generalist model to focus on scientific methods with considerably greater rigor. All medical disciplines reexamined their roles in medical education, delivery of healthcare, and patient centricity; pathology and laboratory medicine was no exception.

In addition to increased technical rigor, attention grew over the ensuing decades to focus on greater evaluation and understanding of the appropriateness (to assess overuse) and necessity (to assess underuse) of medical services. A series of landmark interdisciplinary studies conducted at the RAND Corporation in the 1980s and 1990s highlighted clinical variation in practice and advocated for more explicit criteria to guide diagnosis and treatment. These and other studies served as the basis for more rigorous assessment of clinical evidence, evaluation of practice against that evidence, examination of individual care practices against recognized best practices, and ultimately structuring of payment models to align reimbursement incentives with appropriateness.

Over the past four decades, the discipline of medical quality assessment and improvement has evolved, both scientifically and culturally. Quality control became quality assessment and improvement, and quality improvement became performance improvement. What we recognized originally as performance improvement took a major shift at the turn of the century when the Institute of Medicine published their landmark book To Err Is Human: Building a Safer Health System. This publication and the subsequent publication, Crossing the Quality Chasm: A New Health System for the 21st Century, refocused the dialogue from quality to patient safety. The study and improvement of quality has seen many names over the years; recognizing the goal as patient safety focused attention on what matters most to patients, their safety when seeking care from healthcare systems that exist to reduce the burden of disease and improve outcomes of care.

Patient safety continues to be a primary focus both within healthcare institutions and clinical laboratories. Five decades ago, the laboratory medicine community recognized that laboratory quality depended not only on the analytic quality of the laboratory, but also on the steps that lead up to testing and those that follow. Laboratory quality experts, including the Centers for Disease Control and Prevention, coined the phrase “Total Testing Process,” which encompasses all aspects of testing from the pre-analytical phase starting with formulation of the clinical question that a laboratory test seeks to answer through to the post-analytical phase where the result is reported, acted upon, and impacts patient outcomes. Studies suggest that the majority (65%–70%) of laboratory errors occur in the preanalytical phase, before the specimen ever reaches the laboratory. Another 15%–20% occur in the postanalytical phase. The fewest errors actually occur in the analytic phase of the total testing process, that part of the total testing process most under the laboratory's direct control.

Emergence of laboratory stewardship

Laboratory stewardship programs focus primarily on aspects of laboratory practice that offer the greatest opportunity to improve patient care, particularly including the pre- and post-analytical components of the total testing process. As such, they now receive increased attention in the overall approach to optimize laboratory services. Stewardship programs challenge laboratory professionals to reach outside their analytic “comfort zone,” recognizing that the greatest opportunity to impact the value of laboratory testing comes from engaging external colleagues to focus on pre- and post-analytic components. Accordingly, laboratorians are strongly encouraged to further develop their existing relationships with clinical partners by engaging in conversations on what constitutes optimal patient care for achieving desired clinical outcomes and reduced diagnostic errors.

The holistic approach of laboratory stewardship to enhance laboratory value aligns with broad healthcare aims. Over the past few decades, healthcare leaders articulated and refined a “triple aim” that includes the key goals of better patient experience, better population health, and lower cost. An additional aim, the well-being of the care team, was added later. Laboratory stewardship supports each of these goals: optimal laboratory testing that avoids over- or undertesting improves the patient experience; reduced care variation improves population health; prevention of unnecessary test orders (and associated downstream care) lowers healthcare costs; and streamlined clinical decision support improves clinician practice satisfaction. In addition to these healthcare goals, laboratory stewardship also acknowledges the operational aspects of laboratory medicine, including risk management and reasonable payment from third party payers for medically necessary services.

Opportunities to improve laboratory services exist in every organization. Some of these opportunities may be unique to a specific organization, while many are common across multiple healthcare systems. When challenges to quality patient care are common, specialty societies, payers, consortia of health systems, and others will articulate those issues and promulgate guidelines, recommendations, payment policies, and other programs to close these common gaps. When developed by these healthcare stakeholders, strategies for optimal care are usually specific, explicit, and based on published evidence. Published guidelines and recommendations from trusted organizations are a good starting place for examination of internal practices because they are defensible, recognized by internal stakeholders, and frequently already tied to performance incentives. Many measures are either laboratory medicine–specific or include laboratory diagnostics metrics to measure performance (e.g., percent of patients with diabetes who are regularly evaluated for glucose control).

The Healthcare Effectiveness Data and Information Set (HEDIS) and the Choosing Wisely campaign are examples of integrated efforts to identify measures that improve quality of patient care, including laboratory services. HEDIS began in the 1990s and is now one of the most widely adopted tools for improving organizational performance. This set of metrics is developed by the National Committee for Quality Assurance (NCQA) and is used by health plans and medical groups to evaluate clinician performance against accepted metrics. Provider incentives are frequently tied to performance on accepted HEDIS measures.

The Choosing Wisely campaign was initiated by the American Board of Internal Medicine (ABIM) Foundation in 2012 to promote conversations among physicians, patients, and other healthcare stakeholders on appropriate patient care. In 2013, the ASCP joined Choosing Wisely to start conversation on the appropriate utilization of medical tests and procedures that sometimes provide little or no benefit and, in some cases, cause harm to patients. A multiyear initiative, the Choosing Wisely campaign provides resources for patients and physicians to engage in these important conversations that help patients choose care that is supported by evidence, not duplicative of other tests and procedures already received, free from harm, and truly appropriate. Choosing Wisely pulls together recommendations from many specialty societies based on published, peer-reviewed evidence. These recommendations, in addition to those published separately by medical specialty societies, are good sources to use when identifying or justifying specific performance improvement projects supported by laboratory stewardship initiatives.

National medical societies such as the ASCP that joined the Choosing Wisely campaign initially identified five tests or procedures often used in their specialty whose use, at least in some situations, should be reconsidered. Numerous Choosing Wisely guidelines that focus on laboratory medicine topics now exist, being submitted by laboratory societies (e.g., ASCP, the American Association of Blood Banks, the American Society for Clinical Laboratory Science, the American Society for Microbiology) and by specialty societies that use laboratory tests (e.g., American College of Obstetricians and Gynecologists, American Academy of Family Physicians). For example, in August 2019 the American Academy of Pediatrics recommended not testing for Lyme disease as a cause of musculoskeletal symptoms without an exposure history or appropriate exam findings. They noted: “The musculoskeletal manifestations of Lyme disease include brief attacks of arthralgia with early disseminated Lyme and/or intermittent or persistent episodes of arthritis in one or a few large joints, with predilection for the knee, in late disease. Lyme testing in the absence of these features and without appropriate exposure from living in or traveling to a Lyme endemic area increases the likelihood of false positive results and may lead to unnecessary follow-up and therapy. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.”

Implementation of a laboratory stewardship program

Successfully implementing a laboratory stewardship program requires five key elements: a clear vision and organizational alignment, skills, resources, incentives, and a plan of action. Each element, with examples of implementation, is described in detail below.

A clear vision and organizational alignment

Implementing a laboratory stewardship program is an opportunity for laboratory professionals to drive the change they want to see. It is important, however, that the laboratory's vision (i.e., aspirations) is aligned with that of the organization. Absent a clear vision and organizational support, there will be confusion with little chance for meaningful success. Successful program implementation may require a change or alignment of culture (i.e., the values, beliefs, and norms influencing how people behave as members of an organization) and a shared understanding of why change is needed. Critical to this change management is a solid laboratory professional–clinician partnership.

Understand the health system organization and establish key partnerships with stakeholders

When initiating a laboratory stewardship program, one must first understand the health system's organization and culture. Laboratory stewardship is by nature interdisciplinary, and understanding the health system enables identification of key stakeholders across the organization with whom laboratory professionals will need to partner to achieve desired clinical outcomes. Key stakeholders often include health system medical (e.g., physicians, nurses, physician assistants, pharmacists) and administrative (e.g., safety managers, information technology analysts, quality improvement specialists, members of the “C-suite”) leadership in addition to laboratory medical and administrative leadership.

Traditional organizational structures are changing in response to pressures throughout healthcare; now, organizational structures vary such that an understanding of one does not likely extend to an understanding of others. Traditional departmental medical staff structures still maintain important roles, but alternative structures such as service or product lines have developed to provide an interdisciplinary, integrated care approach when managing specific patient populations (e.g., cardiology, oncology). Therefore, understand how physicians, other healthcare providers, and administrators interact to achieve desired system outcomes so that the stewardship initiative can be integrated smoothly. For example, leaders and departments tasked with improving budget and financial scorecards may have specific targets; laboratory initiatives can help them reach their targets. Health systems usually have working committees focused on quality, infection control, medication management, and medical staff privileging. An existing committee may already be tasked with elements of laboratory stewardship, in which case the stewardship initiative should be integrated carefully and with buy-in from these stakeholders.

Given the importance of physician leadership to every laboratory stewardship program, time is needed to understand the medical staff who use laboratory services. Some physicians may be employed; others might be independent or contracted. These relationships may become relevant when selecting program participants. Alignment may be more difficult when physicians are independent because if their income is generated solely through direct patient care, investing many hours on an “extracurricular” endeavor results in lost income, unless the system compensates individuals for time lost from direct patient care.

Establish leadership and governance for the laboratory stewardship program

A laboratory stewardship program requires dedicated oversight to focus on identifying and implementing needed changes. Before establishing the program's oversight structure, however, recognize how the key administrative (e.g., CEO/COO for the system, or the chief technologist in the laboratory) and medical (e.g., CMO/director of medical affairs for the system, or laboratory director/CLIA certificate holder in the laboratory) leaders intersect in terms of their roles and responsibilities. This is important both to make sure the right people are engaged as initiatives are undertaken and to assure that organizational structures and lines of authority are respected.

The oversight structure may be a specific committee, or a subcommittee or task force, of an existing health system committee (Fig. 1). Participants in stewardship oversight should include stakeholders from the laboratory, inpatient and ambulatory providers, and administrative leaders. Laboratory participants may include pathologists, operational directors, and medical laboratory scientists. Clinical participants may include primary care and specialist clinicians and other staff (e.g., nurse practitioners, nurses, and physician assistants). Health system administrators (e.g., finance, information technology, risk management and process improvement) are important to help integrate and align the program with the broader organization. Additional individuals may participate based on their subject matter expertise related to specific program initiatives.

Figure 1. Possible structure for a laboratory stewardship oversight committee. Regardless of the oversight structure established in a particular health system, participants in laboratory stewardship oversight should include stakeholders from the laboratory, clinic, and health system administration.

Successful programs have a specific point of accountability (e.g., a designated leader or two co-leaders). There must also be a knowledgeable staff person (e.g., a program manager) specifically assigned to the laboratory stewardship initiative. The staff person must keep the program on track by aggregating data, coordinating analyst and other team member activities, scheduling meetings, engaging subject matter experts, and ensuring the leader or co-leaders are always apprised of activities.

Communicate a compelling case for change

Stakeholders must be convinced of the need for a laboratory stewardship program. Laboratory-based stewardship champions must create enthusiasm to secure non-laboratory stakeholder buy-in to create the true interdisciplinary team. Once non-laboratory stakeholders support the program, they can also become stewardship champions who help others recognize the value of laboratory services and secure additional buy-in for the program. The interdisciplinary approach helps assure initial efforts are integrated, make operational sense, and progress toward achieving desired clinical outcomes.

Laboratory professionals can actively cultivate other stakeholders to become stewardship champions. Laboratory medical and technologist members who serve on organizational committees may already have established relationships and credibility with patient-facing physicians and clinical staff. Look to existing successful laboratory-hospital partnerships such as effective blood utilization and antimicrobial stewardship initiatives. Laboratory stewardship can thus be framed as an extension of existing partnerships.

Compelling case discussions should include presentation of data (e.g., declining performance on HEDIS indicators) to establish the importance of selected initiatives and provide the basis for change, followed by discussions on desired outcomes and how to achieve them. Peer-to-peer conversations, rather than lectures that come across as patronizing, can effectively educate stakeholders and promote alignment. When aligning on desired outcomes, the focus should be on achieving beneficial patient outcomes and not simply achieving appropriate laboratory utilization (e.g., correct test ordering patterns). This framing is more inclusive, should align with the organization's strategic plan, and highlights a shared value of laboratorians and clinicians.

Discussions allow stakeholders to share diverse perspectives. Ongoing engagement, especially across departments and disciplines, leads to identification of challenges and opportunities that may not otherwise be recognized. Through collaborative discussion, stewardship champions and key stakeholders can begin developing initial project proposals. Initial projects should each have a reasonable scope so that early program initiatives have the best chance to succeed and prove value. Early successes promote further change and should be widely shared across the organization to build program support. The team can then move on to bigger challenges, including looking at changing deeply ingrained practice challenges.

Skills

A laboratory stewardship program requires analytic, subject matter, presentation, project management, interpersonal, and leadership skills. Rarely all the needed skills to carry out a successful laboratory stewardship program will be embodied in one person. That is precisely why an effective team brings multiple colleagues to the table, each with unique skills and abilities, to define, evaluate, and address problems.

Analytic skills

Every program must have individuals with the right analytic skills to turn large amounts of laboratory and related institutional data into actionable information. Effective analysts are more than computer programmers or database managers, although the ability to access needed datasets is obviously important. Rather, effective analysts have the ability to turn reams of data from hospital information systems (HIS) and laboratory information systems (LIS) into actionable information. The analyst does not necessarily need to have all the clinical knowledge to “massage” the data but must have sufficient grounding to understand what he or she is seeing.

Usually, a preliminary analysis generates more questions than answers. The analyst must have sufficient skills to drill deeper into the data, extract information in different ways, and summarize findings accurately and appropriately. Once familiar with the project and the data, a skilled analyst should ask challenging questions of the entire team. Relevant questions include:

• What are the questions you are seeking to answer? How do they relate to the desired clinical outcomes?
• What clinical and demographic parameters are appropriate?
• Is it appropriate to include all patients, or should the analysis be restricted in some way (e.g., outpatients, children under 18, patients with a particular insurance, those with a specific diagnosis or from a particular clinic)?
• Which laboratory tests should be included? Are there any related tests that should be pulled to check the integrity of the data?
• Do we need to know the responsible healthcare providers or their department(s)?
• What time period should we examine?
• Do we need a comparison group by which to judge the results of an intervention? What should be the basis for comparison (e.g., using the prior period as a baseline or a comparison group that does not receive the intervention)?
• Is this project entirely focused on internal performance improvement or might it be considered research? (This is an important question because generally projects to improve quality do not require institutional review board [IRB] approval. However, there are exceptions, and it is important to engage an IRB when necessary. Check with your local leadership to make sure you remain in compliance.)

Depending on project complexity and the nature of the data, summarizing the data may best be done in a simple table, a graph, or some type of chart. Many software programs exist that can transform data into easy-to-interpret formats. Regardless of the format, the analyst must be able to share with team members what they did to transform the data. Absent an in-depth team understanding, there is a very high risk that some analyses that look attractive are based on erroneous assumptions, sending the team in the wrong direction or creating an embarrassing situation when presenting findings outside the team.

Subject matter experts

It almost goes without saying that subject matter expertise is an important “skill” that must be represented. In the context of a laboratory stewardship program, subject matter expertise includes both laboratory expertise (e.g., laboratory operations, test methodology) and clinical expertise (e.g., cardiology, neurology, rheumatology). The required clinical expertise will change based on the specific project or study. Clinical experts serve several roles, so make sure to select the right experts for success. First, clinicians (e.g., medical, nursing, pharmacy) will help ground the issues to be addressed and provide feedback during discussions; feedback from this perspective is especially important when the laboratory team wanders too far from clinically relevant issues. Second, when the right clinical leaders are part of and support the initiative, they will be able to positively influence their clinical colleagues to embrace findings and initiate change.

Presentation skills

The best information will have little impact unless it is effectively communicated to stakeholders, whether they are team members, organizational leaders, or scientific colleagues. Know the audience to whom the presentation is directed. An identical presentation given to the team, the health system CEO, and an external group of interested colleagues (e.g., at a professional society) will inevitably be either overly general such that it lacks substance, or will contain content that is inappropriate for audiences for whom it was not originally drafted. Each presentation should have a defined goal, acknowledge the needs of the intended audience, and then present data and conclusions aligned with that goal.

Providing detailed instructions on how to give effective presentations is beyond the scope of this discussion. However, publications on audience engagement identify a few key skills that are worth consideration. Garon describes four steps leading to a successful presentation:

• Tailor the presentation to your audience (as mentioned above).
• Organize the presentation (introduction, agenda, goals, methods, findings, conclusions, next steps, as appropriate) so that the audience knows where you are headed.
• Master presentation techniques by outlining the presentation and practicing it for clarity and timing (e.g., present to colleagues or the stewardship committee before presenting outside the group).
• Use effective visual aids.

A slide deck or handouts can help the audience follow the discussion. When preparing a slide deck, make sure the title of each slide clearly reflects the body of the slide and conveys the message you want the audience to receive. For example, title a slide that presents data about the relationship between chest pain and serum LDL as “Most patients with chest pain have a history of elevated LDL” rather than labeling the slide “Data.” This allows the audience to quickly grasp the take-home message so that they listen to the presenter and do not get lost in the details of the body of the slide. Keep slides brief, graphs simple, and messages clear. Engage with the audience, encourage interaction and questions, and seek their input about the findings that you present.

Leadership, interpersonal, and project management skills

The individual within an organization tasked with leading the laboratory stewardship program must not only know laboratory operations, but they must have the skills, personality, and drive to engage others and make them a part of and understand their value to the project. The individual must have the respect of existing colleagues and the ability to gain the respect of new people. They must sell laboratory stewardship outside the laboratory, have confidence in the data, and be sufficiently visionary to see where an effective program will lead.

Leaders must convincingly convey information to others in ways that result in both buy-in and co-ownership of the findings and resultant action plans. Convincing communication requires trust among colleagues, a well-thought-out synthesis of findings, and a servant leadership philosophy (i.e., one that values interaction and recognizes that everybody wins when participants feel empowered). Even the most motivated team members will face anxiety if they perceive the team to lack the necessary skills and cannot envision a pathway to reach the goal. Laboratory stewardship leaders and staff are therefore well-served by project management skills that include developing reasonable goals and effective project tracking to gauge and communicate progress. The most effective laboratory stewardship leaders often emerge as members of the team with the skills to guide the team, ensure goals are accomplished, and celebrate with the team when success is realized.

Resources

Any successful program—and laboratory stewardship is no exception—must have the necessary resources to successfully realize its vision. Without adequate resources, team members will sense frustration rather than success. Decisions will need to be made on whether to develop and allocate in-house resources or outsource selected components of the program; however, program leadership cannot be outsourced.

Human resources

A stewardship program requires personnel dedicated toward the initiative. At minimum, dedicated time for participation is needed from respective key stakeholders, including medical leadership, the laboratory, hospitals and clinics, and administration. The importance of a committed program manager has already been discussed. Depending on the goals and structure of the program, the stewardship team may also require dedicated project-specific manager(s), information technology staff/support, data analysts, financial analysts, educators, and other specialists. There may be a need to supplement internal team member skills with specific external expertise in some areas. Irrespective of who is involved in the effort, individuals must be afforded the time and support required to ensure a successful outcome. Specialty societies (e.g., ASCP) and other organizations (e.g., the American Society for Quality) provide educational resources to help interested laboratory professionals acquire skills needed to lead quality initiatives such as laboratory stewardship.

Equipment, supplies, and informational resources

Material equipment and supplies and informational resources are required to support a laboratory stewardship program. Typical equipment and supplies include software, educational materials, administrative office supplies, and items for team celebration and reward (e.g., small gifts, food). Certain supplies, such as software, are often purchased as a subscription or as a service and require sustained financial resources. Other resources, such as IT infrastructure, may be shared with others in the organization to reduce cost and complexity.

Access to reliable informational resources provides guidance so that program objectives are in accordance with current best practices. The stewardship team should have access to relevant professional societies and their published clinical guidance, including statements and evidence-based guidelines. The Choosing Wisely initiative mentioned previously is a helpful resource for clinical guidance that is publicly available. The laboratory recommendations collected from participating medical societies pertain to five categories of test utilization that may inform program objectives: high-cost and unreimbursed testing, repeat normal testing, repetitive testing, obsolete or unproven tests, and clinical pathway diversions. Other helpful informational resources may include payer policies. Because third-party payers incorporate peer-reviewed publications into payment policies, examining those policies is often useful for obtaining current guidance. In general, payers link their coverage policies to their payment policies, so this information can also provide insight regarding denials for services provided.

Incentives

Incentives for health systems

Healthcare systems, hospitals of all types, and patient practices all articulate organizational missions and visions. A mission statement drives the organization by providing objectives and strategies to achieve those objectives. The vision statement is forward-looking and identifies where an organization seeks to be in the future. Given the central role of laboratory medicine in every clinical practice, an effective laboratory stewardship program helps any organization reach its goals and objectives, supporting the mission and realizing the vision.

Achieving a mission and vision requires an organization to focus on key aspects related to their practice or operation, including the previously discussed quadruple aim:

• Improving patient experience with care
• Improving the health of populations, including a focus on health equity
• Reduction in the cost of healthcare
• Improving provider satisfaction with care

The following subsections discuss how effective integration of laboratory stewardship efforts enhance each of these aims, creating a powerful incentive for any system and its members to engage with the program.

Improving patient experience with care

A positive patient experience with care depends on the health system achieving expected quality goals, reflected by a safe experience, expected outcomes, and satisfaction with care. Health systems are incentivized financially by health plans and government payers to improve and maintain quality patient experiences. Within their communities, health systems leverage results of positive patient experience assessments (e.g., HEDIS scores, U.S. News and World Report Rankings, recognition in local media) to raise the recognition of their systems as centers of excellence for patient care.

Patient experience depends on the efficient functioning of all parts of the health system. While patient-facing laboratory operations (e.g., positive phlebotomy experience, timely and accurate results, accurate invoicing) are important areas of focus for improving patient experience, the information gained through analyses of laboratory performance and utilization informs improvement across systems by guiding appropriate care management, eliminating redundancies, and identifying opportunities to reduce overuse and underuse of medical services.

Effective test utilization, timely result reporting, and a positive patient experience are all metrics that must be included in a comprehensive laboratory stewardship program. When integrated with other health system metrics, laboratory stewardship will be a significant contributor to optimizing patient experience with care.

Improving the health of populations

The last decade has focused increasingly on closing gaps in care, particularly among people of color, individuals with limited resources, and those who are challenged with respect to health literacy. Addressing the health of populations requires attention to more than health services. Health systems committed to population health must be sensitive to all social determinants of health dimensions because many non-healthcare delivery factors have a bigger overall impact on health than the direct provision of healthcare services (Table 1).

Table 1. The social determinants of health Social and economic factors (40%) Health behaviors (30%) • Employment • Income • Education level • Family and social support • Community safety • Diet and exercise • Alcohol/substance use • Sexual activity • Smoking Physical environment (10%) Clinical care (20%) • Air and water quality • Housing and transportation • Access to care • Quality of care

Improving population health requires patients to have access to health services, comfort seeking those services, and knowledge about which services to receive and when. Guideline-driven early screening and preventive services are a key component to improving population healthcare. Beyond impacting the 20% of health driven by healthcare, data and information provided by laboratory stewardship initiatives, with appropriate integration, offer the ability to impact health behaviors and social and economic factors that represent the largest contributions to population health. For example, analysis of laboratory data may reveal missing screening services or new abnormal laboratory test results that may, when probed, indicate resource limitations (e.g., job layoff, loss of safe living conditions) that cause modification of eating habits, substance use, or access to medication.

Reducing healthcare costs

Laboratory stewardship may achieve its initial traction in a health system by providing insights to reduce test overutilization. Overuse is ubiquitous in both the inpatient and ambulatory settings and takes multiple forms. In the inpatient setting patients may receive daily testing for stable conditions. This type of overuse often results from standing orders or the employment of order sets where those ordering the laboratory services select a set of tests rather than selecting each test individually. That is not to say that order sets are inappropriate as they can guide appropriate test selection, but it is important to medically validate the specific content of the order set. In addition, tests ordered during an inpatient hospital encounter may be adversely impacted by acute disease, producing misleading results; they are instead best ordered after the patient is discharged, during a future ambulatory visit.

In the ambulatory setting, laboratory services are vulnerable to overuse and underuse, particularly when care is not delivered as part of an integrated delivery network. For example, overuse occurs when there is repeated ordering of the same tests by multiple providers or when the ordering of tests is more frequent than specified by clinical guidelines for monitoring chronic conditions. Information management may be challenging if an individual laboratory does not have insight into all test orders and results (e.g., one clinician orders a test performed by the health system laboratory and another orders the same test from a reference laboratory whose results are not integrated with the system).

Addressing the cost of care also must consider downstream consequences of laboratory diagnostics, both when patients receive services they do not need and when they are not offered necessary services. Underuse of relatively inexpensive laboratory diagnostics often dramatically raises long-term costs of care because the resultant delays in screening may increase adverse consequences of disease, such as more advanced cancer, poorer diabetes control, and unaddressed dangerous lipid profiles. These issues were highlighted in 2020 during the COVID-19 pandemic where different patient characteristics resulted in different risk levels for disease and disease severity. During the pandemic, the biggest patient threat has likely been underutilization, particularly among tests to manage chronic diseases and in traditionally underserved communities and people of color. Laboratory professionals have access to data that can provide insight into clinical practices and identify potentially pandemic-related gaps in care. A laboratory stewardship program provides a venue for systematic data analysis and positions laboratory professionals as healthcare leaders with a commitment to appropriate, equitable, and efficient care.

Improving provider satisfaction

This discussion does not specifically focus on the fourth healthcare aim; however, optimized laboratory resources, operations, and staff assure clinicians receive the right test, for the right patient, at the right time, ultimately having a positive influence on provider satisfaction with their profession.

Incentives for laboratory stewardship team members and participants

At the outset, and throughout the course of a program initiative, it is important to keep the team motivated. Motivation requires that team members, team leaders, and the organization feel positive about selected initiatives and receive internal and external support to continue their engagement. As an organization launches or continues its laboratory stewardship journey, leaders must assure that the team members maintain the motivation and dedication that initially brought them to the table. This requires ongoing incentives for members that align with their values and motivation.

Many people assume that the most powerful incentives are financial; however, money may be but one of numerous incentives that effectively drive a laboratory stewardship team toward success. Laboratory professionals (including pathologists) are just that, professionals. As described below, team members may feel incentivized by increased recognition and satisfaction, the ability to contribute to improved patient care, and the opportunity for career advancement. Whatever the incentives, they must be relevant to those engaged in the stewardship program. Without incentives, there may be tacit acceptance of the program, but progress, at best, will be slow as other initiatives receive higher priority.

Gratitude, recognition, and celebrations of success

Regular acts of gratitude and recognition from organizational leadership and peers encourage initial engagement and ongoing involvement with a stewardship program. Recognizing and celebrating team success boosts morale and helps link the program's success with a more positive and communal workplace culture, addressing a fundamental and universal human need to be acknowledged by others and for efforts to be valued.

Employee appreciation and recognition programs have become common in the workplace. Psychological research supports their importance; expressions of gratitude lead to enhanced job performance and prosocial behavior. In healthcare settings, studies demonstrate that a positive workplace culture, including effective teamwork and change management, reduces clinician burnout. These findings are salient because about 44% of physicians in the U.S. reportedly experience symptoms of burnout, as measured by emotional exhaustion and depersonalization scales. If the workforce responsible for executing prescribed changes exhibits burnout and low morale, then implementing changes in practice areas, such as how these practitioners use laboratory services, will encounter more challenges and resistance (e.g., “not another organization initiative!“). Acts of gratitude, recognition, and celebration thus create a positive feedback loop: these acts foster a more positive workplace culture that increases the willingness to change, and a positive culture with effective change management helps reduce burnout, leading to improved performance, higher morale, and more occasions for acts of gratitude, recognition, and celebration.

Notes

This presentation is faithful to the original, with only a few minor changes to presentation, grammar, and punctuation. In some cases important information was missing from the references, and that information was added.