SPECIAL FEATURE
T
he “clinical laboratory consultation” model was developed in its most advanced form by Dr. Michael Laposata when he served as director of the clinical laboratories at Massachusetts General Hospital. Laposata developed a rigorous coagulation consultative service to fill the knowledge gap that physicians had regarding appropriate laboratory testing. Laposta currently serves as Chairman, Department of Pathology, University of Texas, Galveston, TX.
Consultative relationships between clinical laboratory experts and clinicians have been challenging, to say the least. Fifty years ago, most laboratories were “tolerated” by clinicians. Dr. Gambino worked to change that mentality by teaching courses on how to better manage hospital clinical laboratories. Among his students were Dr. Paul Brown (who would later found MetPath, predecessor company to Quest Diagnostics), and Dr. James Powell, (one of the founders of Biomedical Reference Laboratories, a key part of what became Roche Biomedical Laboratories, and later LabCorp). These business-oriented
pathologists developed reference laboratories designed to support clinicians. Both entrepreneurs provided medical and technical experts to assist clinicians with test selection and interpretation. Fifty years later, the two reference laboratories grew tremendously in size in part due to the close relationship fostered with clinicians. Dr. Gambino joined MetPath as president of the
eastern division, later served as its first Chief Medical Officer, and went on to become first Chief Medical Officer, Emeritus. His contribution is reflected in the highest quality award at Quest Diagnostics— the Gambino Award. This prestigious award has recognized and encouraged excellence in laboratory quality for more than 20 years.
Gambino Quality Award The Gambino Quality Award honors Dr. Raymond Gambino, Emeritus’s Chief Medical Officer. It is awarded each year based on regional medical quality scorecard, proficiency testing, medical quality audits, and timeliness of adoption of Standard Operating Procedures (SOPs) for both anatomic and clinical pathology. Established in 1997 to encourage and recognize quality excellence within Quest Diagnostics, the award has two levels: (1) a “Challenger” level with criteria that are very difficult to achieve, and (2) a “Winner” level that highlights the extraordinary commitment of a region to specific quality measures.1
Guiding appropriate lab utilization Over the past fifty years, in addition to the Triple Aim principles:
(1) Improve the patient experience of care (2) Improve the health of populations
(3) Reduce the per capita cost of healthcare
development of independent laboratories, the in vitro diagnostic industry exploded along with regulatory oversight. Most notable, the Clinical Laboratory Improvement Act (CLIA ’67) and the CLIA Amendment of 1988. Immunohistochemistry and molecular diagnostics opened new doors to understanding disease and medical risk. Quality control and quality systems became embedded in our culture. Yet, the consultative role in the clinical laboratory remains largely elusive. Many clinical pathologists and medical scientists still operate on the one-on-one consultation model along with broader communications through newsletters, lectures, webinars, and courses. Fast forward to present day. The groundwork set forth by Dr. Gambino to establish quality laboratory practices aligned with the needs of patients has evolved to another level with the development of laboratory stewardship. This is a phrase that typically refers to the use of laboratory data to guide appropriate utilization of services and minimize inappropriate use. Clinical laboratories are embarking on a path that allows rules embedded in electronic medical records (EMRs)
to guide appropriate laboratory utilization and limit inappropriate utilization.
Roots of laboratory stewardship Laboratory stewardship has its roots in blood bank committees that oversee appropriate blood utilization. Even though blood banks are closely associated with the other clinical laboratories, these practices did not extend far to the other side. Clinical labs have touched upon other “utilization” teams. Infectious control committees have focused on appropriate antibiotic use within hospitals. And pharmacy committees have often focused on use of less expensive comparable medicines. While laboratory stewardship has its foundation in blood bank utilization management, it is fundamentally more expansive. Laboratory stewardship focuses on principles of the framework of the Triple Aim: (1) Improving the patient experience of care (quality and satisfaction); (2) improving the health of populations; and (3) reducing the per capita cost of healthcare. As pressure mounts on costs associated with
healthcare, laboratory utilization management focuses increasingly on cost control to understand who is ordering which tests—especially expensive tests and referral testing.
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