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There are multiple names for lab utilization programs today: test utilization, lab utilization, and lab stewardship to name a few. They all support the same goal, but each word communicates a slightly different message in a world and time where words matter. HPI connected with Dr. Jane Dickerson, Director of Chemistry, Director of Reference Lab Services, and the Medical Director at the North Clinic at Seattle Children’s Hospital, and Clinical Associate Professor, University of Washington, Department of Laboratory Medicine. She weighed in on the topic, sharing her affinity for the word stewardship as it communicates a feeling of being on a team, with a shared responsibility to manage a limited resource which she quickly notes has never been more true than right now.

Laboratory stewardship has two main stakeholders – the most important being the patient. When someone goes to get a lab test collected, they know that the lab result is going to impact the clinical decision making of their care team. They expect everything to go well from the beginning to the end. Unfortunately, we know that errors happen – not just in the lab. It is very hard sometimes to select the right test, to interpret a complicated test result or to even get the result back in a timely fashion. The communication of these reasons – test selection, interpretation, retrieval of lab results – are often the biggest causes of lab related litigation and ultimately patient harm. Laboratory stewardship programs put a bubble around this process, helping providers select the right tests, make sure that the interpretations are clear and visible, and facilitate timely retrieval of those results back to the care team and the patient for the second stakeholder, the healthcare system. Health plans are also invested in this process. They want to optimize the value of lab tests as well, paying specific attention to quality and cost. Stewardship programs can qualify the over/under and miss utilization of lab tests as well as the bottom line, including how much money the patient will be responsible for versus how much money the system is going to absorb. This information and analysis are becoming more important as healthcare institutions continue to find themselves balancing crisis alongside the need to provide care. We asked Dr. Dickerson to share the key drivers, even in pandemic times, of starting and maintaining a thriving lab stewardship program.

Limited Resources
Labs have struggled to have the right supplies to perform lab tests, long before COVID-19. Shortages for everything from tubes to reagents, on top of limited staffing to keep up with demand. Clearly not prepared for a pandemic, many hospitals have had to redeploy staff specifically for COVID testing, which comes at the continued expense of other lab testing. While we scramble to meet the critical testing needs across the country, the already limited budget is being compounded with furloughs, capital equipment or hiring freezes, and medical or executive leaders taking on a larger role in managing lab testing because of COVID-19. The lab has never been more prominent than it is today, providing a stewardship program a unique opportunity for visibility. If you need something, now is the time to ask for it. At a minimum, get an informatics resource to create a COVID-19 dashboard. You can then apply that resource to other tests as we slowly gain a capacity to think about other things.

Success starts with culture
Success has a lot to do with the culture of your institution and culture is no doubt shaped by leadership. Dr. Dickerson suggests engaging a few high-level stakeholders in the beginning of your program to create a few hospital wide policies. If those members can’t attend regularly, having them peripherally involved is still helpful because they remain an effective champion in driving change. This might be a person in the lab, a physician leader or executive from the hospital administrative side. The key is their support early on in providing data to the program, to identify, monitor and maintain the interventions put in place. Then, on an as needed basis, begin inviting service line leadership. For example, if you’re talking about genetic specific testing or gastroenterology, not everyone needs to be there. Dr. Dickerson is firm in pointing out that a program does not automatically need to have 30 people at the table – you can do a lot with a small group who’s committed.

Success continues with clear goals . . . and expectations
Dr. Dickerson continues, recognizing that success will look different depending on the institution and program goals. I think it’s key to have realistic expectations going in and celebrate small wins. These may be as simple as getting a few key policies through the system that didn’t exist before or finding an intervention that’s measurable that doesn’t take years to get consensus on. Basically, something that’s not controversial that everyone can agree on and doesn’t require a ton of resources from the outset. Then, over time, you use those small wins to gain traction, get known within your institution, and subsequently be able to ask for more resources.

Success persists when you engage external resources
There are external resources available as well for hospitals or health systems starting a stewardship program. Dr. Dickerson emotes gratefulness as she describes the lab community as “sharers”. There are really no shortages of resources that you can find. I think one of the more publicly facing resources is of course Choosing Wisely (www.choosingwisely.org). They have a lab section with guideline templates and clinical lab standards for laboratory stewardship and utilization. Then of course, there’s PLUGS: Patient-centered Lab Utilization Guidance Services. PLUGS has its own national lab stewardship committee that has put together guidelines and resources you need, including the people you need at the table and a checklist to easily identify areas that are lacking or need more support.

PLUGS is a nonprofit within a nonprofit within Seattle Children’s Hospital Department of Laboratory. The organization was formed in 2012, when genetic testing was taking on a life of its own. The initial mission was to provide guidelines for these new tests to ensure they were the right tests to best diagnose or inform a patient’s care. A few years into their work, they realized that all institutions shared the same questions, applied to all laboratory testing. Today, with an expanded mission, PLUGS is a network of over a hundred like-minded organizations that share experiences, interventions, policies, and tools. These are collected and shared frequently on their website (www.schplugs.org).

Profoundly Impacting Healthcare
When asked how PLUGS is making an impact on healthcare, Dr. Dickerson doesn’t hesitate. I think the biggest way PLUGS is making an impact today is through our partnerships with health plans. This is not considered the friendliest place to drive change, but it often feels like there’s these big silos in healthcare: the hospital, the patient, and the insurance plan. We really wanted to bring those together to find where we have common goals. PLUGS has clearly done so, consistently updating and writing policies for previously uncovered esoteric tests that have now been adopted by many payers and cover millions of lives. Connecting the payer and the patient, they have developed kits to guide families through the preauthorization process, so they’re not burdened with large bills at the conclusion of testing or treatment and continue to submit applications for new codes to help apply national coverage policies to lab tests. Each year we make incremental progress. We’ve got great friends across the health plans, institutions, and commercial labs. I’m proud of the community we’ve created and the impact we’re making.

It’s time to PLUG in. Or PLUGS. Success starts with one step forward. Take it.