Improving Patient Care and Reducing Costs through Laboratory Stewardship

The Laboratory Stewardship Committee at PeaceHealth, a community-based healthcare system in the Pacific Northwest with hospitals and clinics in Oregon, Washington and Alaska, spearheaded efforts that have delivered savings of $2.25+ million for patients each year after discontinuing procalcitonin testing—and an additional $1.6+ million in gross annual patient savings by changing in-house testing menu to guide providers towards ordering troponin I for acute myocardial infarction.

Defining the value of Laboratory Stewardship

Mohiedean Ghofrani, MD, MBA, System Medical Director for Laboratory Services, defines the value of PeaceHealth’s laboratory stewardship committee with simple grace. In sum, the committee’s goal is to ensure everyone is getting the right test at the right time, while avoiding doing tests that “add no value to the care process, increase costs, cause patient dissatisfaction, and leave providers frustrated and confused by conflicting information.”

In more detail, Dr. Ghofrani notes that PeaceHealth’s Laboratory Stewardship Committee is focused on:

1. Avoiding over- and under-testing. As Dr. Ghofrani explains, “We are committed to preventing unnecessary test orders so we can lower healthcare costs and improve patient satisfaction. Imagine if you can avoid one unnecessary needle poke or if you can avoid a patient getting a false positive result, and the associated adverse outcomes -- that's huge both in terms of cost savings and patient satisfaction.” On the flip side, Dr. Ghofrani notes that the issue of under-testing is especially problematic within underserved communities, and “communities of color that might be not have easy access to necessary testing.”
2. Selecting the right tests for the diagnosis under consideration. “We’re working hard to counter the misconception that more tests mean better care, and that’s why a key component of our laboratory stewardship efforts involves critically reviewing some testing practices,” notes Dr. Ghofrani. “Our goal here is to both improve patient outcomes and help streamline clinical decision support.”
3. Critically reviewing some standard practices, such as panel testing. “Some of these panels were built years ago, and it’s important to review these panels with some regularity to make sure those tests are still the best up-to-date tests,” mentions Dr. Ghofrani, “especially since Laboratory medicine is advancing continuously and new and better tests are always becoming available.”

Ensuring the success of Laboratory Stewardship

According to Dr. Ghofrani, a Laboratory Stewardship Committee that can deliver on both its promise and potential requires these key strategies:

1. Solicit support from executive leadership: “One of the reasons our Laboratory Stewardship initiative has been successful,” says Dr. Ghofrani, “is because we first solicited and received buy-in from our executive leadership—and our supportive chief executive for our medical group saw the value in this initiative, and promoted our work throughout the healthcare system; he knew who to recommend for membership on the committee.” As a pathologist, Dr. Ghofrani knew the lab leadership and talent, and the resources available in the lab, but he was less familiar with the talent in the broader system. “So having that support from the chief executive and CMO was really helpful because they knew which clinicians and others would be invested in this process.”
2. Ensure committee membership is broadly representative: “We knew,” notes Dr. Ghofrani, “based on the literature, and on the work of other healthcare systems, that we needed a committee that represents not only the lab and clinicians, but also the wider system. So beyond pathologists and clinicians, we wanted to have executives, financial analysts, operational thinkers, informaticists, and IT experts.” Dr. Ghofrani strongly believes that this broad array of expertise is essential to justify the committee’s importance to clinicians and justify its costs to executive leadership.
3. Provide sound numbers to justify expected savings. Dr. Ghofrani shared this example about the importance of justifying the numbers: “When we wanted to implement a project where the vendor projected savings in the thousands of dollars for each patient, we took that number with a grain of salt.” Dr. Ghofrani and his colleagues presented the vendor’s numbers to their financial analyst, who came up with a number that while lower, still showed savings. “That's why we want to have financial analysts vet the numbers: we want to get everything right,” says Dr. Ghofrani.
4. Be rigorous about defining the scope and impact of the problem. To help reduce costs and improve care, laboratory stewardship committees must anchor their efforts in an informed understanding of the problem. According to Dr. Ghofrani, “We always do the data analysis, and make sure our decision-making support tools and IT team help us grapple with the data. IT support is especially critical in terms of getting the baseline data we need so we can be sure that what we are seeing is really a problem or not.” For instance, it’s crucial to determine if there are individual hospitals that are over-utilizing or under-utilizing a test—or if it’s a systemwide issue and what is the scale of the issue. “Is the amount of waste worth creating a whole project for it? If it’s a very small problem, then maybe it’s not worth tackling—and you have to have the data ahead of time,” warns Dr. Ghofrani.
5. Embrace transparency and encourage engagement. Change is always a challenge, and “you can't force change on people, you can't just say, ‘By the power of my authority, I'm going to tell you to do this from now on’ -- it's not going to work that way,” cautions Dr. Ghofrani. “People will always find ways to avoid change if they're not invested in it, and if they're excluded from the process.” So, Dr. Ghofrani, the chief executive for the medical group, and the CMO worked hard to include as many stakeholders as possible in every discussion, so no one ever felt denied the chance to provide input. “Our decisions benefited hugely from different voices and different perspectives—and allowed colleagues to take ownership for every decision—and to feel valued,” says Dr. Ghofrani.
6. Show your love to your IT team and have the right data analytics tools. “After you implement the intervention, you’ll need to continue to collect data to see how much of a change you've been able to make, how much you have been able to improve patient care and lower costs,” says Dr. Ghofrani—and measuring outcomes is only possible with the right IT support. Moreover, having the right data analytics tools can help accelerate the pace of projects.
7. Don’t be annoying. As everyone knows, the road to hell is paved with good intentions, and it’s not enough to mean well: it’s the doing that matters. For example, Dr. Ghofrani explains, “If a clinician is ordering a test, and there’s a better option available, the simple thing is to have an alert show up, just add a warning.” The problem? “Clinicians are inundated with hundreds of warnings coming from different sections of the healthcare system and we didn’t want our message diluted in this deluge because we know that after a while, clinicians are just going to ignore the warning.” The solution? PeaceHealth’s laboratory stewardship committee turned to the expertise of their informaticist who designs alerts/warnings to be effective—never annoying.
8. Recognize that change requires persistence. “Change takes time,” notes Dr. Ghofrani, “so we just keep chipping away—and we recognize some factors are beyond our control—and we accept this limitation. Still, over time, we’ve learned that persistent effort is fundamental to success: without any doubt, persistence delivers better patient outcomes, reduces the cost of care, and improves the overall patient experience.”