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SPECIAL FEATURE


partners for the first few projects starts with finding people who already understand the value of such activities.


1. Identify amendable problems; define project charter or scope. 2. Develop project team (may be standing committee). 3. Extract, standardize, and analyze data. 4. Apply solutions to the problem (input). 5. Size the change and reiterate until problem is rectified, resolved (output) with process to assure monitoring; also involves communications. For lab managers that do not have specific projects


IDEAS is five-step model for projects:


to consider, two key resources may yield insights into areas for attention: The Choosing Wisely campaign (choosingwisely.org) initiated by the American Board of Medicine and PLUGS. Choosing Wisely focuses more on what not to do than what to do. It aims to reduce or eliminate activities that have little benefit or may cause harm. Many of the recommendations have already been adopted. The other key resource is PLUGS, (Patient-centered Laboratory Utilization Guidance Services) which is a non-profit laboratory stewardship collaboration within Seattle Children’s Hospital Department of Laboratories, a consortium of more than 70 organizations. PLUGS is a leading resource center for laboratory stewardship with templates, webinars, newsletters, conferences, and individual support and consultation. PLUGS describes


four basic elements:2 t Governance t Intervention t Data extraction and monitoring t Review of data coupled with strategies and tactics for improvement.


Real world examples One laboratory stewardship project that I’ve been involved in included review of duplicate orders for molecular diagnostic tests. In this study, nearly every circumstance involved orders from two or more physicians who did not review pending orders. Another project involved an unusual test whose order code reflected two inverted digits. In these examples, the problems were identified and exploration uncovered the causes. Applying strategies such as Six Sigma Quality or standard QA tools helped to identify the root causes. Wrapping these activities into laboratory stewardship provides a framework to assign resources to gather issues, prioritize, and solve. Laboratory stewardship can be even more impactful


by identifying patterns of utilization and specifically, potential underutilization, and over-utilization. Although there is a tendency to focus on high-cost services, examining low-cost services has the potential to reduce waste, too. For example, routine ordering of CBCs in patients without out-of- range results and no deterioration in medical status can be wasteful. Creating checkpoints to order high cost tests or tests ordered “too frequently” can act as a road bump


that reduces inappropriate test utilization. Creating checklists that apply to common conditions can act as reminders for appropriate test utilization. Another avenue for laboratory stewardship is clinical decision support (CDS). CDS involves rules that are triggered by prior test results, test ordering, other clinical measures or events, and time. For example, specific ages of patients can trigger reminders about immunizations. Another example is patients with diabetes should have at least one HbA1c test every six months (patients with diabetes can be identified by ICD-10 codes, prescription of hypoglycemic agents, or prior evidence of diabetes, e.g., multiple elevated HbA1c or fasting glucose results).


Coverage and reimbursement Finally, a key aspect of laboratory stewardship is obtaining appropriate payment for services provided. This includes obtaining CPT codes from the American Medical Association CPT Editorial Panel, coverage policies that cover the intended use of clinical lab testing and services, and proper reimbursement. The laboratory community must be committed to voicing the necessity for appropriate coverage and reimbursement as a way to provide patients with testing and services that meet their needs.


In conclusion Many clinical laboratory initiatives have presented themselves in the past 50 years. However, laboratory stewardship is one that will continue to flourish. We have come a long way since MLO started with Dr. Gambino’s one-on-one approach to educating clinicians about the strengths and limitations of clinical laboratory testing. As a result, we can now better leverage learnings among institutions and the data that sits in our data repositories. Laboratory stewardship provides a new, more ambitious model with access to big data that encourages us to focus on improving the health of patients. I, like so many other physicians, laboratory


technologists, and medical professionals, have been inspired and influenced by Dr. Ray Gambino. Thank you Dr. Gambino for pioneering a path that has lead us to best serve clinicians and their patients.


REFERENCES


1. The 2019 Gambino Quality Award. Quest Diagnostics. http://blog. questdiagnostics.com/2019/05/2019-gambino-quality-award/. Accessed July 8, 2019.


2. Dickerson JA, Fletcher AH, Procop G, et al., Transforming laboratory utilization review into laboratory stewardship: Guidelines by the PLUGS national committee for laboratory stewardship. Journal of Applied Laboratory Medicine. 2017.


Harvey W. Kaufman, MD, serves as Senior Medical Director, Medical Informatics, Quest Diagnostics. Kauffman has worked with Dr. Ray Gambino and others at Quest Diagnostics for 27 years in a variety of roles including its first Chief Laboratory Officer. Kaufman now focuses on application and licensing of healthcare data, with the goal of providing insights and improving health outcomes.


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