4 Tips for Creating a Successful Laboratory Stewardship Program

As the effects of the COVID-19 pandemic and inflation continue to create uncertain economic conditions, hospitals are being asked to cut costs—in some cases upwards of 15 percent. As a result, for hospitals, efficient lab stewardship is now more important than ever to support business performance and provide excellent patient care.

What is lab stewardship?

Thirteen billion tests are performed in the US annually, and 70 percent of post-test medical decisions are based on pathology and laboratory medicine results. 

Yet, as hospitals are pressed to optimize quality, finding adequate financial coverage for testing is increasingly difficult. With inflation and an increase in labor costs of up to 37 percent between 2019 and 2022, all hospitals are feeling the crunch.

Lab stewardship refers to correctly ordering, retrieving, and interpreting laboratory tests. Getting these steps right ensures that patients and clinicians receive the important information they need without extra steps or costs, improving the quality of patient care and reducing costs to both patients and hospitals. 

Hurdles to optimizing lab stewardship

Most hospitals and hospital systems have some room for improvement. Errors in ordering, retrieving, and interpreting tests can lead to diagnostic errors and are costly to the patient and hospital. Many of these errors include overutilizing routine lab tests, ordering low-value tests that do not impact patient outcomes, and provider confusion when multiple tests with similar names are listed in the system.

Clinicians and other health care providers can easily make the wrong selection when ordering a test—10 percent to 30 percent of laboratory tests performed in the US are either unnecessary or ordered in error. Technology can be used to reduce the likelihood of human error and to find optimized cost efficiencies for hospitals.

How to set up a successful lab stewardship program

The good news is that these hurdles can be overcome with the support of a structured lab stewardship program. Here are some steps on how to set up a successful program:

 1. Obtain support from executives

Buy-in from hospital executives is crucial to ensure the operators that establish and run a lab stewardship program are empowered to make decisions. Because lab stewardship and testing affect multiple areas within hospitals, everyone from the top-down must be aligned on these updates. Executives can also help prepare teams to accept changes, which may cause temporary inconvenience while benefiting patient care and the hospital as a whole. 

A successful lab stewardship program is governed by a committee that has representation at the hospital level. The scope of the committee should determine intervention levels (e.g., education, soft stops, hard stops, etc.) to guide clinicians when choosing testing and govern new lab test requests. 

2. Use data to drive stewardship

Laboratory stewardship committees should start by analyzing laboratory data to identify areas of waste and inappropriate ordering. Reviewing current practices will help the committee identify targeted interventions to correct these wasteful practices, including establishing evidence-based guidelines to assist clinicians in choosing the correct testing. The committee should then track and monitor the result of these initiatives and interventions to determine success. Conducting research to evaluate new testing options is also critical.

3. Confirm software optimization and algorithms

Check in on the software optimization and algorithms available in the computerized provider order entry (CPOE) system to ensure there are prompts, guidance, and/or education provided to clinicians and providers for choosing the appropriate test. 

Nomenclature is important; in non-optimized systems, there could be two similar lab tests, with one alphabetically displayed above another in the list within the system. However, that order does not necessarily reflect which test is more common or the most appropriate. Clinicians and providers must be made aware of all existing test options and how to choose the correct one. 

For example, vitamin D 25-hydroxy is the most commonly ordered test for general vitamin D deficiency screening, unlike vitamin D 1,25-dihydroxy, which is not an appropriate order for general screening. However, when listed alphabetically, vitamin D 1,25-dihydroxy may be listed first, often causing providers to accidentally choose the wrong test for routine vitamin D screening.

Instead, hospitals should optimize their systems to highlight or list the most common tests first. Additional software optimizations could include: 

• Order alerts for duplicate or once-in-a-lifetime test orders 
• Approvals or notifications for genetic testing that costs more than a set dollar amount
• Additional information attached to test orders, such as test descriptions to assist clinicians with ordering

Making these simple changes within the system provides autonomy for clinicians and providers and promotes timely and cost-effective testing for patients and hospitals.

4. Ensure initiatives and interventions contribute to the overall business strategy

Lab stewardship programs can support a hospital’s overall business strategy by driving better patient care, creating more appropriate test ordering, and supporting better outcomes for patients. Developing a successful strategy includes obtaining executive buy-in, regularly reviewing lab testing data, and investing in and optimizing software and technology. Ultimately, lab stewardship strategies improve the quality of patient care and reduce costs to both patients and hospitals. 

Lab stewardship in the time of COVID-19

Improving lab stewardship is not as challenging as it may sound. When COVID-19 testing began, many new testing options became available, and determining which test was appropriate for which patient was challenging at times. For example, tests that could detect up to 22 different pathogens were not needed for patients with a mild infection, yet health care providers would often select the test they spotted first in the list. By optimizing testing systems, using evidence-based clear guidelines and education, and using a patient-driven approach, providers have the tools to guide them to make informed decisions on which tests are appropriate for any given patient, including considering the cost. 

Steps to improve lab stewardship can both improve care and reduce costs. While a complete program is most effective, as a first step, lab operators can implement small changes that will eliminate unnecessary testing and human error, as well as add clear guidelines around ordering to rein in costs.