Rewriting one systems lab stewardship story

Effective laboratory stewardship is essential in healthcare, but that doesn’t mean it’s easy. Building a sustainable, clinician-driven program requires structure, collaboration, and involving the right parties.

In 2016, healthcare leaders at M Health Fairview — a partnership between the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services — launched a laboratory stewardship initiative centered around a single academic hospital. Although there was strong intent and laboratory-led momentum behind the effort, limited multidisciplinary engagement and informatics support made adoption challenging. Without system-wide alignment, progress slowed, and the enterprise faltered.

Luckily, that’s not the end of the story. In 2021, M Health Fairview revisited the effort, with a fresh, system-level perspective and commitment to change. With support from ARUP Laboratories’ healthcare advisory services, leaders formed a planning committee to redefine the vision, draft a charter, and identify key parties. They focused on community and collaboration.

Laying the groundwork

This time around, the initiative faced new logistical and staffing challenges because of COVID-19, and leaders were required to emphasize reducing wastage and optimizing specialized testing. In the midst of the pandemic, laboratory functions gained leadership’s awareness, which prompted timely action.

For example, the laboratory transitioned to a new laboratory information system (LIS): Epic’s anatomic and clinical pathology Beaker modules. This shift presented new electronic health record (EHR) ordering and clinical decision support tools, in addition to richer data for creating reports that highlighted areas of needed intervention.

The LIS changes further increased the lab’s visibility with executive leadership, giving the stewardship committee sustained momentum. The clinician-led, multidisciplinary collaboration included physicians, pharmacists, nurses, operational leaders, IT personnel, and informatics specialists. Laboratory informatics and administration leaders aligned stewardship goals with EHR functionality, data access, and clinical workflows, ensuring that provider input shaped decisions.

With ARUP’s support, the committee leveraged expertise from the broader laboratory community through online forums, referrals, and national organizations such as the American Society of Clinical Pathology (ASCP) and Patient-centered Laboratory Utilization Guidance Services (PLUGS). Committee members asked for collegial consultations and engaged in knowledge-sharing about specific strategies and lessons learned.

The team built a strong foundation by defining roles and responsibilities, establishing a charter and mission, creating a data-driven process for prioritizing and approving initiatives, developing templates for meetings and reporting, and identifying IT and data needs to support intervention.

In January 2022, the Lab Stewardship Steering Committee was formally launched with broad representation across the care continuum, including professionals from ambulatory care, infectious disease, pediatrics, hospital medicine, pharmacy, nursing, quality, IT/informatics, and pathology.

Data as the foundation for progress

The committee spent most of its efforts during their first year developing and validating the data tools to inform priorities and guide change. These tools included native EHR analytics such as SlicerDicer and the ARUP Analytics Comprehensive Dashboard to review test volumes, orders per encounter, and cost impact. The data gleaned from these tools enabled a spectrum of insights, ranging from understanding healthcare utilization at the population level to learning how one individual used a given test. It provided a 10,000-foot view of the overall testing landscape.

Early wins and building momentum

With the structure in place, the committee quickly identified and prioritized initiatives, including daily lab utilization optimization, a metagenomic NGS access and ordering intervention, inpatient thrombophilia testing optimization, peripheral blood morphology review reduction, and the formation of a system laboratory and pathology diagnostics committee (Table 1).

Table 1:

Intervention	Description	Intervention type(s)	Champions	Stage
Daily lab utilization optimization (10 high‑volume tests such as CBCs and BMPs)	Implementing 3-day repeat order expiration duration on most inpatient orders	Clinical decision support, education	Internal medicine, Critical care medicine	Implemented
Metagenomic NGS access and ordering intervention	Implemented restriction for Karius tests to be ordered by infectious disease providers only	Access intervention, education	Infectious disease, microbiology, laboratory	Implemented
Inpatient thrombophilia testing optimization	Creating an order set support paired with alternative test alert suggestions to guide inpatient testing	Clinical decision support, education	Hematology, coagulation laboratory	In progress
Peripheral blood morphology review reduction	Streamlines smear review triggers and uses automation + education to reduce manual peripheral morphology reviews when not clinically necessary	Automation, education	Hematopathology, hematology	In progress
System laboratory and pathology diagnostics committee	Establishes a governance structure for evaluating, approving, and monitoring reference lab tests to improve utilization and cost stewardship	Access intervention, automation, education	Multidisciplinary	Planned

Early wins in these areas established credibility and highlighted the value of a coordinated, clinician-led approach.

Case highlight: Daily laboratory utilization, system strategy

One of the most collaborative initiatives focused on providing clinical decision support to prevent automated daily recurring lab orders, particularly for high-frequency tests such as complete blood counts (CBCs) and basic metabolic panels (BMPs). Historically, these tests could be ordered without expiration for the duration of a patient’s stay, which led to unnecessary utilization and increased costs.

After extensive collaboration with frontline providers, IT, and system clinical and laboratory leadership, the committee implemented a new EHR ordering design: Daily laboratory orders would expire after a maximum of 3 days, requiring renewal if still clinically appropriate. To support this change, 10 new laboratory test order codes were created with built-in expiration logic.

Recognizing the need for flexibility, the team carefully reviewed and exempted specific order sets, such as those used in the ICU, neurology, pharmacy, oncology, and long-term acute care settings, where continuous monitoring is essential. These exemptions were tightly controlled and tied to provider specialty profiles in the EHR.

The rollout affected about 700 order sets and was executed with minimal disruption despite its broad scope. Providers received virtual support, along with proactive education and communication to help address concerns. Issues were reported through the system’s incident reporting tool, ensuring tracking and accountability for resolution. Evaluation of the early intervention data and continued monitoring for needed improvements is in progress.

Impact-driven strategy

What began as a stalled initiative has evolved into a dynamic, clinician-led systemwide program that continues to grow. The Laboratory Stewardship Steering Committee now meets regularly, tracks interventions and outcomes, and reports directly to executive leadership, ensuring visibility and alignment with broader system goals.

A centralized SharePoint portal was developed and continuously updated to serve as the program’s documentation hub and collaboration space. It houses all stewardship work, including charters, meeting minutes, project tracking tools, and educational materials. The portal also includes a submission form for new project ideas. This form makes it easier for clinical staff and leaders to contribute to ongoing improvement efforts.

Intentional sustainability

This journey didn’t happen overnight. Every step has been purposeful. From its early beginnings in 2016 to its strategic relaunch in 2021 and formal committee launch in 2022, the program has steadily matured into a model of sustainable, system-wide transformation. The timeline reflects a willingness to pause, reassess, and rebuild with intention.

A key factor in the program’s long-term success has been its commitment to sustainability and embedding long-term value in healthcare delivery. The Laboratory Stewardship Steering Committee now operates with defined annual goals, a dedicated financial analyst, and a structured process for tracking both clinical and financial outcomes. This ensures that stewardship efforts remain aligned with broader system priorities and will continue to deliver measurable value year over year.

The team actively monitors metrics (Table 2). Insights inform timely adjustments, such as refining order sets, the ability to focus on targeted use cases for deeper analysis with custom reporting to better conserve limited analytics resources, and engaging providers and specialty groups for feedback and suggestions.

Table 2:

Metric category	Example metric	Measurement type	Timing
Adoption	% clinicians using preferred workflow	Utilization rate	Pre vs post
Issues/concerns	# reported workflow issues	Qualitative/quantitative	Ongoing
Goal alignment	Impact on clinical, safety, or resource goals	Outcome indicator	Pre vs post
Cost impact	Cost per test (e.g., Karius $X/Unit)	Financial metric	Pre vs post

 

By prioritizing clinician leadership, investing in infrastructure, and staying committed to collaboration and transparency, the health system has built a laboratory stewardship program that not only supports better patient care, but also serves as a blueprint for sustainable, systemwide transformation.

Michelle Stoffel, MD, PhD, is the associate chief medical information officer and medical director for laboratory medicine and pathology informatics at M Health Fairview. She is also an assistant professor and program director for the clinical informatics fellowship at the University of Minnesota. +Email: [email protected]

Klint Kjeldahl, CT(ASCP), is vice president of M Health Fairview Laboratory Services.

Brenda Tomanek, MLS(ASCP), is system director, laboratory services across the M Health Fairview System.

James Grace, MD, is an assistant professor in the division of hospital medicine at the University of Minnesota.

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