CEO SUMMARY: In Toledo, Ohio, ProMedica Laboratories uses extensive metrics to analyze almost all processes in the lab. Under a process improvement program in place for more than five years, the lab has implemented daily management to help streamline day-to-day operations. Concurrently, a newly-formed cross-functional test utilization team adopted recommendations from the Choosing Wisely campaign that uses the same detailed data to assist physicians when ordering lab tests.
SOON THE CLINICAL LABORATORIES of every hospital and health network will need to pursue cost savings relentlessly while sustaining the high quality of lab testing services. This strategy will be needed to survive deep laboratory test price cuts from government and private payers.
Recognizing this growing need to cut costs, ProMedica Laboratories in Toledo, Ohio, has a process improvement team that uses analytics and targeted metrics to monitor the lab’s performance while also reducing costs and improving patient care.
By applying metrics to as many processes as possible, the lab staff can demonstrate when and how improvement takes place in key performance indicators, said Samanthia Rousos, BSSE, KL, PPC, and Amanda Wright, MLS (ASCP), both of ProMedica Laboratories. Rousos is the Process Improvement Engineer and Wright is the Quality Management Specialist for the lab.
“While our primary goal in using the data is for continual improvement in work processes, the lab also uses analytics and selected metrics to identify ways to eliminate unnecessary testing as the Choosing Wisely campaign has recommended,” noted Rousos during a presentation with Wright at The Dark Report’s Lab Quality Confab in Atlanta in October.
One approach to managing laboratory test utilization involves using metrics to analyze tests as they arrive at the core laboratory facility, which serves as a reference lab for all of the hospitals in ProMedica’s 13-hospital system.
Multi-State Health Network
As is the case in most large health systems, the ProMedica lab serves many customers including a level one trauma center, staff physicians, independent physicians, and a newly-implemented residency program. The nonprofit health system serves patients in Northwest Ohio and Southern Michigan. It has 17,900 employees and 2,700 physicians, meaning the size and scope of the health system make it a challenge for the clinical laboratory to manage lab test utilization appropriately systemwide.
When the lab began its test utilization project, it had two important resources at its disposal. “First, our lab had extensive data on the lab’s performance over the prior five or more years,” noted Wright. “Second, our lab uses the quality management system (QMS) of ISO 15189: Medical Laboratories, and our lab staff understands these methods.”
When the lab sought to engage physicians and nurses in projects to improve lab test utilization, staff decided to implement recommendations from the Choosing Wisely campaign, Wright said. An initiative of the ABIM Foundation, Choosing Wisely aims to avoid unnecessary tests, treatments, and procedures.
The Choosing Wisely campaign recommends that clinicians use four criteria to assess whether a test is needed or can be eliminated. The lab staff needs to determine if the test in question is:
- Supported by evidence;
- Not duplicative;
- Free from harm; and,
- Truly necessary.
Work Group Established
With support from ProMedica’s administrators, the lab established a work group that included a pathologist, laboratory staff, ordering physicians, and residents to review tests on its menu according to the Choosing Wisely recommendations.
One example is a test recommendation that says physicians should not request a serum creatinine assay to test adult patients with diabetes or hypertension for chronic kidney disease. Instead, Choosing Wisely recommends that clinicians order a kidney profile test, which is serum creatinine with eGFR (estimated glomerular filtration rate), and the urinary albumin-creatinine ratio.
“It is important to recognize that some of these recommendations ask physicians to change his or her daily habits,” added Wright. “Creating the structure to implement these recommendations requires a lot of support from your IT department to make those changes. For that reason, we started by making a few smaller changes that might be easier to do and still have some effect on ordering.
“Once our work group approves a change in test ordering, we allocate the resources and make the necessary changes in the order sets and frequencies,” Wright explained. “When you look at changes in lab test utilization, one outcome to track is the financial effect of such changes.
Test Utilization Support
“In 2013, Choosing Wisely said labs should not perform repetitive CBCs or chemistry if the patient is stable,” Wright explained. “That might sound easy enough. But if you tell your physicians, ‘You’re only going to have one CBC today,’ they might freak out.
“At that point, we thought our lab might want to start even smaller and suggest that physicians not do more than one differential per patient per day,” she said. “To estimate the effect of that change we needed to know how many differentials we do every day and on which patients.
“So, the lab team counted the number of times someone ordered a differential within 24 hours on the same encounter number,” Wright said. “We determined there were about 350 repeated differentials a month. The cost of each differential is $2.60. Multiplying that price by 360 per month showed that we could save $11,232 per year.
Quick and Easy Savings
“At that point, we made some changes in our LIS system and saw that we could potentially save that $1,000 each month, or $12,000 per year,” she added. “That might be a small amount, but it’s something our lab could do quickly and relatively easily, it saves money, and it is a win that has clinician support. Plus, several modest wins like this add up to a significant amount of yearly savings.”
In a second initiative, the lab staff identified more savings by targeting inappropriate ordering for urinalysis, Wright said. “Annually we perform about 20,000 urinalysis tests with reflex to culture, and 38.2% of those reflex cultures are unnecessary due to outdated reflex criteria. So, cutting the number of UA tests that require a culture by almost 40%, the potential savings could be $19,335.”
In summation, Wright explained that all of the work collecting data on specific lab tests allows the lab to answer questions that physicians will often ask when any lab seeks to improve the processes physicians normally use. “We have an infrastructure that supports our efforts,” she said. “We also have a work group comprised of peer physicians and residents who have agreed to these changes. In addition, we know how much money we can save, and we have the literature to back it all up.”
Analytics, Targeted Metrics
In addition to projects designed to improve lab test utilization, the staff at ProMedica Laboratories is using analytics and targeted metrics to drive down costs throughout the laboratory while also improving quality.
“We use, and regularly revise, key performance indicators,” Rousos explained. “Our ProMedica core lab has metrics in place across the board in all of our hospital laboratories and in all six departments in our core laboratory.
“About five or six years ago, we started a daily management program,” she said. “In that time, we have measured almost all—but not quite all—of our processes. And that’s our goal: to implement metrics fully for as many processes as possible.
“To do that, we need to constantly change our metrics by continuously improving them,” commented Rousos. “Once we improve a process in our laboratory, the metrics need to be fixed or changed. Or, put another way, we need to set new targets.
“The way our lab team does this is to assign metrics that directly relate to a strategic or quality objective,” Rousos explained. “If these metrics don’t relate to a goal, then they operate in a vacuum where they become just like the headache of the day. When that happens, metrics will not get our lab to where it needs to go.
“Metrics also need to be smart, meaning specific, measurable, attainable, relevant, and timely, as in the acronym, SMART,” she said. “We define a measurable metric as one that addresses cost, quality, or time.”
ProMedica Lab Studies Urinalysis Test Use
ONE LAB TEST UTILIZATION PROJECT at ProMedica Laboratories focused on urinalysis (UA). “We wanted to determine if we could do fewer urinalysis tests that reflex to culture,” said Amanda Wright, ProMedica’s Quality Management Specialist.
“Many labs offer a reflex option for urine cultures, and I would challenge those labs to review their reflex criterion,” she noted. “Under our criteria, we reflex the culture anytime the UA shows greater than 10 white blood cells, positive LE [leukocyte esterase], positive nitrites, or moderate or greater than moderate bacteria. That’s a lot of urine cultures, which might be unnecessary.”
In considering the design of this lab test utilization project, the work group suggested a different evidence base and a more stringent approach. Wright gathered the data needed to show the difference from one approach to another. “I wanted to know how using the new criteria would affect the number of tests we would now reflex to culture,” she explained.
“When we did the math, we found we could save $19,000 annually by adopting the new criterion,” Wright said. Due to various patient populations, ProMedica offers a standalone urine culture (UC) option, but Wright said if a lab offers only a UA with reflex to UC test, the savings could be significant.
The changes the lab’s process improvement staff made were not isolated to the lab, Wright added. “We’re expected to drive down rates of C. Difficilebecause antibiotic usage declines. Also, we should see an increase in reimbursement because our catheter-assisted urinary tract infection rates should go down as well. Research shows that when health systems implement such policies, that’s what happens.”
In each department, the staff holds a daily two-part huddle. In the first part, staff will have a five- to 10-minute communications review including safety, recognition, events for the day, and improvement ideas. Second, the staff records the metric for that day as either red or green, marks the trend for the day, week or month, and documents countermeasures, or possible solutions to the occurrence of the defect. Larger process problems can go through more in-depth problem-solving with a process improvement team.
“Throughout the system, we have anywhere from 700 to 800 reports coming out on some regular interval of frequency,” she added. “The majority of those reports are daily.
“We break out productivity metrics by person, by hour of day, and by other criteria which each department establishes for filtering the reports,” she said. “For example, we can sort our metrics for all tasks and ordering by hospital, such as the ProMedica Toledo Hospital. And, we have a metric for the phlebotomy team staffed at that hospital sorted by name and by how many collections each phlebotomist does.
“That level of detail tells us how well they’re doing and who’s doing what work,” she explained. “All that information will show up in a summary for each day. For example, we can quickly see how the phlebotomists performed at ProMedica Toledo Hospital on any date and any shift.
“Having this kind of detail allows us to match productivity with demand by location,” she added. “We can see who’s doing what at which location and where we might need to shift resources, especially in places where we use float phlebotomists. Now we can ask, for instance, why did they have only two draws in this one location?
“We also have a metric report for specimen defects,” Rousos said. “In acute care, we look for specimen redraws, meaning how many were hemolyzed, or clotted, or QNS—meaning quantity not sufficient. We enter those codes in our LIS, so that our report can look in the comment field and pull out these three acronyms. That way, we can identify and count each defect.
“When we started counting these redraws, we saw that about 3% of redraws were hemolyzed,” she commented. “Now it’s down to the 1% level, which is better than the market standard.”
Attacking Sources of Waste
In conclusion, Rousos explained that all of the work collecting data on lab processes is now producing a significant return on investment. It allows staff to identify where waste is within the lab’s processes and develop improved processes that will benefit patients and their clinical providers in terms of timeliness of results, quality of the result, or price of the test.
The other significant factor in the successful use of metrics is that the ProMedica lab team was trained on Lean and quality management methods. Thus, as metrics were developed, the lab team knew how to use that information to improve work-flow and deliver value to physicians and patients.
Contact Samanthia Rousos at firstname.lastname@example.org, or Amanda Wright at email@example.com.