CLN - Focus on Laboratory Stewardship
Laboratory stewardship is a strategic approach to achieving the optimal test utilization practices for high-quality yet resource-efficient healthcare. Training the next generation of laboratory testing stewards is crucial for sustaining appropriate utilization practices and ensuring that stewardship principles will evolve in alignment with emerging testing methods and technologies. While gaining medical and technical knowledge during training is critical, lab education systems should also expose trainees to the “when” behind testing, along with the “why” and “how.”
Teaching the principles of appropriate utilization is a practical way to bridge the gap between medical knowledge and laboratory practice. For example, learning that a hemoglobin A1C reflects the approximate 120-day lifespan of a red blood cell can help reinforce the learner’s understanding of physiology and the rationale for performing the test (1). Additionally, optimizing test utilization allows trainees to experience the logistical processes of clinical ordering in a way they otherwise might not get to experience within the lab.
Any laboratorian can champion stewardship initiatives. To that end, individuals in training for a variety of laboratory roles can have stewardship principles incorporated into their pre-job or on-the-job training. An example for phlebotomist trainees could be a basic introduction to stewardship concepts that includes the importance of collecting specimens at the intended time. The training could highlight the fact that if drug monitoring tests are drawn too early or too late, it can lead to inaccurate results and a wasted draw.
Training also can include case studies to demonstrate that having a questioning attitude at the bench or bedside can lead to utilization improvements. For example, a technologist may notice that a platelet count is ordered on a subset of patients who had a platelet count upon admission. The investigation may lead to the discovery that the order set used for this patient population has a platelet precheck to establish a baseline. Improvements can then be made to uncheck the default platelet order in the order set to promote only ordering if there is no current platelet result. Incorporating stewardship training for new hires thus lays a foundation for continuous improvement related to the use of healthcare resources.
Laboratories may wonder, “How can we get trainees involved in stewardship work in the short term, even if we don’t have an established laboratory stewardship committee?” Every laboratory will have new staff onboarding and may implement a combination of structured and informal training such as training guides, job shadowing, or quiz modules. The training period for any role is an ideal opportunity to incorporate stewardship principles and provide an avenue for feedback when new trainees identify opportunities to improve utilization.
For example, training materials might include introductory concepts around appropriate utilization, such as calling out that certain tests like high-sensitivity troponin may have an intended ordering interval that aligns with systemwide algorithms. High-sensitivity troponin may default to “STAT” priority and may need to be repeated within a specified time interval, like 2 hours. However, troponin should not be repeated sooner than clinically intended because doing so may not give the clinician the needed clinical information.
Inefficient workflow often leads to inappropriate test utilization, but the root cause of the issue may be hidden within complex processes. For example, clinical users may order an acute test too frequently due to concern that reordering will be missed because of a lack of needed clinical decision support, such as order sets to guide standardized ordering. There also may be a completely different reason, such as barriers to canceling unwanted tests that are already ordered. Mapping out the current state process can prevent implementing stewardship interventions aimed at inaccurate root causes of poor utilization.
Trainees are ideal individuals to engage in this work for several reasons. First, mapping the workflow helps the trainee learn the culture and background of the system. Second, trainees have fresh insights and can often suggest great ideas for improvement. Third, workflow mapping is a valuable skill for trainees to learn and can be used in many other career areas.
Engaging trainees in stewardship data analysis provides opportunities for a broad range of collaborative interactions. Trainees can be coupled with senior faculty, clinicians, and even operational leaders when engaged in stewardship projects, and they can provide capacity for the healthcare teams by owning segments of the data analysis. Trainees also can use stewardship-related data analysis as a basis for establishing their skills and credibility as laboratory professionals. An example of how stewardship projects can build data presentation skills is for trainees to submit abstracts to conferences and copublish with faculty in medical journals.
When working with trainees on mining data for utilization insights, it is fundamental to ensure that the data accurately models the specific stewardship activity. Thus, having a little of the “right” data is more important than accessing large amounts of nonmeaningful data. It is also important to discuss examples where limitations to the data may exist due to the design of the laboratory information system (LIS). An example of a data limitation in anatomic pathology utilization work could be having negative immunohistochemistry (IHC) control slides categorized in the LIS as IHC antibodies, which could inflate IHC antibody utilization data if these slides were not excluded. Once trainees understand the power of selecting the correct data and specific data curation methodologies, they will gain insights into the power of data-driven decision making and problem solving that can lay the foundation for a lifetime of informed practice.
Every laboratory stewardship initiative will require communication with stakeholders, whether it is understanding the needs around utilization or announcing that a change has been made that affects clinical ordering. Trainees can be involved in creating and disseminating these communications. For example, if a new order set to support appropriate infectious disease testing is being implemented, trainees could help identify the specific clinical stakeholders who would benefit from communication about the new tool, such as internal medicine physicians, and draft communication to distribute to rounding teams. Participating in interdisciplinary communications requires learning how to think about the needs of clinical stakeholders and patients and offers an additional way to broaden clinical perspectives outside the lab.
Laboratory stewardship work involves change management by design, and the decisions and priorities discussed during stewardship work can serve as a model for consensus-building in a trainee’s future practice. For example, if a trainee can participate in a multidisciplinary decision to insource a genomic test to the hospital lab rather than sending it to a reference lab, they may listen to laboratory and clinical leaders’ respective viewpoints, observe collaboration strategies, and experience conflict resolution. Similarly, learning how to prioritize limited resources while balancing high-quality care is another important leadership skill that stewardship work can build in trainees.
In summary, equipping lab trainees with stewardship principles in the learning environment helps build confidence in providing appropriate and sustainable patient care in their future careers.
Brooke A. Gagner, MS, HTL(ASCP)CM is the anatomic pathology practice manager at Fairview Health Services in Minneapolis, Minnesota. +Email: [email protected]
Brenda A. Tomanek, MLS(ASCP) is the director of laboratory operations at Fairview Health in Minneapolis, Minnesota. +Email: [email protected]
Michelle Stoffel, MD, PhD is the associate chief medical information officer for laboratory medicine and pathology at M Health Fairview health system and an assistant professor in the department of laboratory medicine and pathology at University of Minnesota in Minneapolis. +Email: [email protected]