Chair's Message
September 2023 - Lab Stewardship
Laboratory test results inform or influence 50-70% of clinical decision-making and treatment planning (Arshoff L et al., Healthc Manage Forum. 2021). Unfortunately, studies have documented significant rates of unnecessary or inappropriate lab testing and delays in (or lack of) retrieval of lab results. Collectively, this leads to misleading test results, erroneous diagnoses, unnecessary costs to patients/health care systems and hospital-acquired anemia; this also can result in unnecessary subsequent testing (lab or other), unnecessary referrals and significant patient anxiety.
Laboratory Stewardship programs work to ensure patients receive the right test at the right time. As we as a nation pivot towards the concept of “value-based” care, effective Laboratory Stewardship programs, along with expert pathologists/laboratorians, will be critical in helping us achieve high value care.
Departmental Laboratory Stewardship programs are more successful in organizations that embrace this culture. We are fortunate and delighted that our Laboratory Stewardship efforts align with UCLA Health’s clinical institutional goals of enhancing patient safety and quality, improving access to care and ensuring financial sustainability. The Department of Pathology and Laboratory Medicine is committed to collaborative teamwork in laboratory stewardship by partnering with our clinicians, administrators and leadership.
An integral part of a Laboratory Stewardship Program is leadership commitment and governance. Department leadership is pleased to be making important investments into these programs, including recently recruiting Dr. Allison Chambliss as our Director of Laboratory Stewardship and Monique Trinh as our Program Manager. UCLA Health leadership also has been extremely supportive of our programs, and has supported our governance structure, described below.
The Laboratory Stewardship Task Force (LSTF) is our lab-based group that develops and executes goals that ensure patients get the right test at the right time. LSTF composition is shown at right and this group meets twice monthly. The overarching goals of our laboratory stewardship program include:
- Improving the ordering, retrieval, and interpretation of appropriate laboratory tests, and;
- Developing, maintaining, and improving systems to provide proper financial coverage for medically necessary testing.
LSTF Co-Chairs: Dr. Allison Chambliss, Dr. Joshua Deignan, Alex Martin, PA (ASCP), MHA; Program Manager Monique Trinh, MHA
The LSTF reports quarterly to the Laboratory Stewardship Oversight Committee (LSOC). The LSOC (membership shown at left) consists of key UCLA Health leadership to provide oversight to the LSTF, assist with system-wide implementation efforts and raise requests for LSTF action.
Pathology Co-Chairs: Dr. Allison Chambliss, Dr. Omai Garner
RECENT ACCOMPLISHMENTS
Earlier this year, the LSTF announced the successful approval (by the LSOC, Ambulatory Policy Committee, and Inpatient Policy Committee) of significant revisions to Health System Policy 1309 (entitled “Laboratory Specimens - Referral to Outside Laboratories”). The main goals of these policy revisions were to 1) streamline the referral lab review/approval process to ensure compliance with the California Department of Public Health requirements, 2) reduce the inappropriate or wasteful use of referral labs by UCLA providers, and 3) enhance the utilization of available in-house testing. An additional new policy (currently under review) will establish appropriate uses of reduced rate testing offered by reference laboratories.
The revised HS 1309 policy can be found here. This policy now further solidifies the role of Pathology and Laboratory Medicine in the oversight and selection of appropriate send-out tests (and laboratories) and, in the future, will likely aid in significantly reducing the use of “miscellaneous” free-texted referral lab test orders. Reducing the “miscellaneous” orders, in turn, will allow us to better monitor our use of outside tests/labs in a continual effort to ensure the best tests and test usage for our patients.
Additionally, the LSTF has updated and digitized (via Smartsheet) the reference lab test request form (16069) for providers to request new send-out tests. Recent enhancements to the form include the addition of questions related to the number of patients who may need the test annually and the degree of physician group consensus for the medical necessity of the test. Each new submission is reviewed by the LSTF for approval prior to initiating new test builds in CareConnect. As needed, subject matter experts outside of the LSTF (including other Pathology faculty) are consulted for their expertise in various testing areas.
Ongoing Projects:
Reference Lab Optimization
Problem Statement:
High use of "miscellaneous" reference lab test orders (for tests not available in CareConnect) is inefficient and causes delays in test ordering and result retrieval.
Proposed Solution:
Identify and prioritize high-volume, high-impact, and analytically and clinically appropriate reference lab tests to be built as directly orderable and interfaced in CareConnect.
Goals:
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Develop a report to monitor miscellaneous test orders;
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Build ~150 new tests in CareConnect;
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Reduce use of miscellaneous order workflows and measure efficiency improvements.
Project Champions:
Dr. Allison Chambliss, Dr. Joshua Deignan, Dr. Alyssa Ziman, Marivic Visico, William Werre, Alex Martin, Monique Trinh
Ongoing Projects:
Inpatient Genetic Testing
Problem Statement:
Genetic testing in the inpatient setting can be problematic due to long turnaround times (e.g., results reported after discharge) and high costs that are not typically reimbursed under diagnosis-related group payment models. Results from a national survey indicate that 75% of institutions require some level of approval for inpatient genetic tests.
Proposed Solution:
Implement a CareConnect alert requiring Laboratory Medical Director consultation and approval for selected inpatient genetic test requests.
Goals:
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Ensure medical necessity;
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Ensure appropriate communication of results to patients;
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Improve access to genetic counseling and test reimbursement.
Project Champions:
Dr. Joshua Deignan, Lana Rapoport
FUTURE PLANS
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Implement CareConnect order frequency alerts for laboratory tests ordered too close in time for the same patient
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Proactively address the utilization of tests with the potential to be audited by CMS
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Contribute to national laboratory stewardship benchmarking and harmonization efforts
We are open to YOUR ideas for new laboratory stewardship projects and focus areas! Contact an LSTF co-chair or Monique, or submit to the new LSTF suggestion box!
Check out our new Laboratory Stewardship Task Force display board outside of CHS 13-262!
Sarah M. Dry, MD
Professor & Chair, Department of Pathology & Laboratory Medicine