Hospital laboratories are facing a variety of challenges in meeting the demand for their services. Challenges include increased test production costs, reduced reimbursement, a shortage of laboratory personnel, and continuing supply disruptions and materials shortages.
The demands and muscle memory of today’s healthcare environment are strongly inclined toward ordering more tests and utilizing older and more familiar test pathways. While physicians are keen to use the latest implants, devices and pharmaceuticals, many remain attached to traditional laboratory tests and ordering practices despite scientific advancements in laboratory practice. What’s needed is a better test selection process.
In our previous blog, we introduced a demand management model and shared how it can serve as a pathway to address ongoing hospital laboratory challenges by supporting better and more timely testing while improving laboratory responsiveness, enhancing testing capabilities and reducing waste.
Creating a better test selection process requires a structured framework within a demand management program. We’ve found that one framework familiar to clinicians—the five rights of medication administration (or 5Rs)—can be very effective when adapted to hospital laboratories as it can be used to evaluate test orders and to assist in establishing a laboratory formulary.
Adapting the 5Rs for use in your hospital laboratory
One of the ways clinicians are taught to reduce medication errors and harm is by using the 5Rs. These principles help to ensure that the right patient receives the right drug and right dose via the right route at the right time.
When it comes to the utilization of hospital laboratory services, physicians’ test orders may be based on prebuilt order sets, many of which may not have been evaluated for clinical relevance for decades. Encouraging physicians to apply the familiar 5Rs to laboratory test orders as a part of a demand management program presents a window for busy clinicians to pause and consider tests’ appropriateness.
One of the things that make demand management so effective is the governance phase and governance structure. The governance group, which is collaborative by design, should consist of physicians, pathologists, scientists, quality professionals and others involved with laboratory usage. The group collects and analyzes laboratory use data from myriad sources such as laboratory information system orders, reference lab usage, HIS reports or third-party tools, such as those offered by Vizient. The group then compiles its findings and recommendations and publishes them for review and discussion with those who are primary laboratory users to seek additional clinical input.
Adapting the 5Rs can provide a helpful framework for discussion during this stage as well as during implementation of any recommended changes. As the group evaluates the findings, they should evaluate recent scientific methods and clinical practice guidelines to determine if the tests are:
The right test—Is this the best test to inform clinical decision making
The right frequency—How often should this test be ordered
The right time—When is the optimal time to conduct this test
The right patient—What is the optimal patient profile for this type of test and does the patient fit the profile
The right cost—Is this a cost-effective test
Putting it into practice: patient with cardiac distress
The governance group of a hospital laboratory’s demand management program identified high-level use of the cardiac marker test CK-MB to assess acute myocardial infarction (AMI). Based upon the group’s review of current scientific and evidenced-based medical literature, it found that the use of this test to diagnose AMI was discouraged and that the literature strongly pointed to Troponin as the preferred test (the right test).
The group also found that testing for Troponin at initial patient presentation and three hours later (the right frequency and the right time) was the recommended timing for determining if a patient is experiencing acute myocardial infarction (the right patient). Unlike Troponin, a specific biomarker that increases with cardiac distress over a three-hour period, CK-MB is not cardiac-specific which is the reason it is no longer considered to be a right test for evaluating myocardial infarction. Its elevation can be caused by problems other than cardiac distress such as renal failure, skeletal muscle injury or exposure to certain drugs or toxins. Current scientific and evidence-based medical research supports the use of either Troponin or high-sensitivity Troponin testing to assess cardiac damage.
The group assembled the peer-reviewed literature and other sources of information and data along with its recommendations into a compendium that was shared with laboratory users. Feedback was received and responses to questions and concerns were published via a communications portal.
The net impact was that the CK-MB test was reclassified as a non-cardiac specific marker, removed from the automated laboratory order entry system and deleted from cardiac panels where it was a component. This change assisted in shortening the response time for cardiac marker testing by approximately eight minutes, reduced waste in the laboratory by eliminating over 12,000 unnecessary CK-MB tests annually and reduced annual laboratory direct costs by an estimated $110,000 (the right cost).
Adapting the 5Rs provides a structured framework for test selection in a hospital laboratory demand management program. The governance group provides the structure to implement changes in physician ordering which can help reduce waste and focus the hospital laboratory on providing the most relevant information in the timeliest manner. With clear goals and meaningful data, the processes will support enhanced patient care while improving laboratory capabilities, responsiveness and reduced costs.
If you need assistance developing a demand management strategy for your hospital or conducting a demand management audit, feel free to reach out to us for assistance.
About the authors:
Mark Tiemeyer has been a consulting director with Vizient for 12 years. Prior to Vizient, Mark directed contracting activities in laboratory, purchased services and general medical for a large health system for nine years. Mark is a medical technologist by background, having managed and directed hospital and reference labs for over 14 years. Mark brings experience in change management and assembling diverse stakeholders to evaluate, select, negotiate and contract to maximize value for stand-alone hospitals to integrated delivery networks.
Walter Valliere brings more than 49 years of experience leading initiatives to grow market share and reduce operating costs through process improvements, strategic outsourcing, business restructuring, business consolidations, supply chain optimization and new venture development. During 10 years with Vizient, Valliere has also held principal leadership/ownership positions with both a multi-site, multi-state independent laboratory and a specialty consulting firm that served the biotech, biopharma, and health care industries. He also holds certifications in ITIL, PRINCE2 project management, and Six Sigma.