Creating a System-Wide Culture of Laboratory Stewardship at Cleveland Clinic

Thanks to the efforts of the Laboratory Stewardship Committee at Cleveland Clinic, the hospital system has saved over $8.5 million in laboratory test-related costs since 2011—and improved patient outcomes, increased clinician satisfaction, and reduced risk by implementing data-driven evidence-based best practices. Originally founded by Gary W. Procop, MD, MS, FCAP, the committee is now co-chaired by Anita J. Reddy, MD, MBA, a pulmonary/critical care specialist, and Walter H. Henricks, MD, FCAP, vice chair of the Pathology and Laboratory Medicine Institute, and laboratory director, Main Laboratories.

What’s Required for Laboratory Stewardship Success

Drs. Reddy and Henricks detail 10 strategies other hospital and health care systems can employ to establish their own laboratory stewardship committees—or improve the efficacy of their existing committees.

1. Find advocates within the ranks of institutional senior leadership. Both Drs. Reddy and Henricks laud the support they received from many senior physician leaders, including the chair of pathology and laboratory medicine, Dr. Brian Rubin, and Chief Medical Operations Officer Dr. Robert Wyllie. Dr. Wyllie “gave the committee his strong support and was able to elevate the work of our committee by sharing the importance of our efforts with other executive leaders.” Dr. Wyllie and other advocates helped “market”’ the committee’s efforts by emphasizing its significance as “an enterprise level priority.” To this end, Dr. Henricks stresses the special importance of engaging the support of clinician leadership champions, such as Dr. Reddy: “Clinical leadership at the highest level is crucial to success because this is not strictly a laboratory effort—it’s designed to benefit the entire system.”

As part of their efforts to mobilize the necessary support, Dr. Henricks and Dr. Reddy developed a charter that articulated the charge and parameters of the committee. The charter helped them “get buy in and essential sign off from executive leadership.”

2. Bring pathologists and clinicians together. Dr. Reddy highlighted the need to bring laboratory medicine experts together with bedside clinicians to “partner together to discuss opportunities to identify and eliminate unnecessary testing protocols, reduce costs, and improve patient satisfaction, safety, and outcomes.” Her co-chair agreed, noting, “It’s essential to make sure the right stakeholders are involved in identifying projects that will yield value. It's not just lab stakeholders, but more importantly, clinical leadership.”

According to both doctors, having clinical leadership—including physicians and nurses—on the committee is crucial to credibility. Genetic counselors from the laboratory also serve on the committee. Further, Dr. Reddy mentioned the wisdom of “choosing individuals who have an interest in this topic. They don't have to be experts, but you do want stakeholders who have a vested interest in the work of the committee.”

3. Establish the committee’s credibility from day one. Choosing the first project well is important since successful initial outcomes provide a chance to build trust. According to Dr. Henricks, “…a combination of factors will help determine what initiative has the highest chance for success,” and those factors will vary depending on the particular environment. Most simply put, he recommends identifying an initial project that “is the easiest to justify based on the literature around certain practices, or for which there are already interested clinician groups disproportionately affected by a given intervention.” Both doctors also suggest looking at the potential financial impact of a proposed intervention, including pre-authorization or the reimbursement impact to the patient.

4. Make data analytics a key priority. Developing a close relationship with data analytics groups is essential, and in this regard, Dr. Henricks reserved special praise for Dr. Reddy. “Dr. Reddy has been instrumental to ensuring we have the data, from institutional data sources, that we need to make sound decisions,” said Dr. Henricks. “I can’t even describe how important she has been to developing ties with our enterprise data analytics group from the early stages.” Insights from the enterprise data analytics group, coupled with assistance from a laboratory data analytics team and financial analysts, have helped the committee dissect utilization questions that have “real implications for how we practice medicine, serve as careful stewards of our finances, and take the best possible care of our patients.”

At Cleveland Clinic, there’s no resting on their laurels. As Dr. Henricks noted, “We are constantly working to make even better use of our analytics—to look at our impact and how we might provide more information to the organization regarding potential opportunities and the impacts of our intervention.” While he and Dr. Reddy believe the committee is doing well documenting the effects of their interventions, they want to expand the use of analytics to develop predictive models, hoping to determine what they can do to “save more and do more for our patients.”

5. Measure and report the outcomes your initiatives deliver. Both doctors emphasized the importance of “being able to demonstrate and document the impact” of every initiative. “You need to document how your model delivers financial savings and helps improve patient outcomes and the patient experience, ” said Dr. Henricks. No laboratory stewardship committee can enjoy success if no one “figures out how to get the hard data that makes the savings clear or shows other value.”

6. Leverage the capabilities of the electronic health record (EHR) system. “Interventions are hardwired into our EHR, which is Epic®,” said Dr. Reddy, “including hard stops and soft stops, notifications of high-cost tests, and stopping individuals from ordering genetic tests more than once in a lifetime.” Incorporating such interventions into care processes (eg, test ordering) is essential because provider education is helpful only to a certain degree, given the turnover endemic at academic medical centers. As Dr. Reddy explained, “You can't continually educate and capture all of those individuals, so you have to find ways to hardwire interventions and have alerts that educate within the EHR.”

To that end, very recently, the committee “implemented an intervention in the inpatient setting in the EHR to alert clinicians when a patient has had normal values for selected labs for three days in a row and encourage clinicians to reduce the frequency or discontinue daily lab orders.” By working closely with their information technology team, the committee is working to “make the EHR provide more intelligent feedback and more meaningful information to the clinician, at the time it is needed, so they can make better decisions for patient care.”

7. Regularly evaluate the tests and panels in your formulary. Health care organizations may not periodically evaluate which laboratory tests should be removed and/or replaced with new and better tests, or less expensive tests. Drs. Reddy and Henricks have led the effort to make sure the tests in their formulary are the best choices available and are targeted to patient needs. Dr. Reddy remarked that “We systematically remove outdated tests or expensive tests if there's a better, less costly test available. We’re keeping up to date with the latest and greatest.”

Input from the laboratory medicine and clinical experts provide crucial input to identify opportunities to remove or to update tests available. While Cleveland Clinic’s Laboratory Stewardship Committee is focused on reducing costs, the committee is also “focused on optimal utilization for patient care … [and] to educating clinicians about what tests should be ordered and which tests should not,” commented Dr. Henricks.

8. Accept responsibility for educating clinicians about the best testing options. Speaking from the clinicians’ perspective, Dr. Reddy commented, “Sometimes clinicians don't always know the high costs of the tests they are ordering—or may not know a new and better test is available.” She also noted, “Often, when we're at the bedside, we have the ability to order whatever we want…but a lot of these high-cost tests aren't always covered by insurance, and that cost gets passed on to the patient.”

In addition to high-cost tests, Dr. Reddy mentioned the importance of assessing “the impact of high volume, low-cost tests, which can also have a huge financial impact”—and negatively affect patients: “Patients are often subjected to repeated blood draws, which are often done during early morning hours. We want to reduce the number of times patients get stuck!”

Finally, both physicians mentioned that sometimes clinicians can be influenced by very aggressive vendors from commercial laboratories offering new and/or highly specialized tests. To mitigate this risk, “Our committee has gotten embedded into the process by which vendors and labs market new developments and tests to clinicians,” said Dr. Henricks. “While it’s not like the old days of pharmaceutical reps coming in and trying to convince doctors to prescribe their products, our clinicians are often approached, and our committee gets involved in those talks—which gives us the chance to advocate for both our clinicians, our send out laboratory section, and our patients.”

9. Serve as a control review mechanism for vetting new test requests. Related to the previous point, when there is a request to add a new test to the formulary, the Laboratory Stewardship Committee consults with experts to “help determine if the recommended test is appropriate to make available, with or without ordering constraints.”

The process considers the implications in terms of insurance coverage, the costs to the institution, the logistical implications, and other impacts for patients. As Dr. Henricks stressed, “…we address these many aspects because we want to confirm the test’s validity.” Based on consultations with experts and involved specialists, “we may decline to add a test either because there is insufficient supporting data, or it’s inappropriate for practice,” said Dr. Henricks, “or we may say ‘Great, this is appropriate for our practice.’” Another possibility is that a test may be made available only to certain specialties. In essence, Cleveland Clinic’s committee serves as a gatekeeper functioning to protect the hospital system and its patients by ensuring additions to the formulary reflect best practices.

10. Identify the requisite administrative support. Dr. Henricks stressed that while “It may sound basic, administrative support has been essential to the success of our committee—especially for helping us manage logistical challenges, such as scheduling meetings and even more importantly, managing the work of the committee such as meeting agendas and minutes and project tracking.” In fact, Drs. Reddy and Henricks “hold bi-weekly check-ins with their administrative support person” to review status of current and planned projects. What the doctors learn in these meetings helps them think through challenges and identify solutions before anticipated problems impede the committee’s efforts; their focused attention delivers results because “No problem can withstand the assault of sustained thinking.” True, according to Voltaire—and according to Dr. Walter Henricks and Dr. Anita Reddy.