Inspired by the Choosing Wisely® campaign, a committee led by residents at Vanderbilt University Medical Center is driving cultural change through a “challenge” aimed at reducing unnecessary daily lab orders. Structured as a friendly, team-based competition, the initiative is already showing signs of success in multiple ways.
At the beginning of each month, committee members meet with new residents and attendings to introduce them to the initiative and answer questions. This is followed by an email with additional resources, including reference articles and charge information showing the costs patients bear for the lab tests.
Four teams, each consisting of two internal medicine residents and one attending, compete against each other over the course of a month. They receive weekly emails tracking their individual team rates, as well as the collective results from all teams. At the end of each month, a more detailed report is disseminated to the full department. The team that avoids the most unnecessary lab orders is declared that month’s winner.
“One of the most important aspects of this effort is that we’re not trying to be restrictive – we’re not eliminating the staff’s ability to order tests that they think are needed,” said Wade Iams, MD, internal medicine resident and Co-Chair of the Vanderbilt Choosing Wisely House Staff Steering Committee.
The committee’s efforts appear to be paying dividends. Before the intervention daily complete blood count (CBC) and basic metabolic panel (BMP) rates were approximately 90%. A goal was set to lower the rate to below 70% – a number staff members say they’ve been able to achieve on a consistent basis.
“A critical part in making these conversations possible is that this has come up through the residents,” said Jack Starmer, MD, Chief of Quality Informatics and faculty advisor. “It’s not something the hospital said you need to do. It’s not hard coded in to the IT systems for order entry. We’re having people think about the things they’re ordering.”
While the competition aspect may serve as a motivational tool, the true aim is to improve patient care and satisfaction. Each month the committee shares information on how patients across the system benefited by not having unnecessary tests. For example, in May the initiative resulted in:
- 308 unnecessary labs eliminated
- 77 misleading lab results avoided
- $38,222.78 saved by patients
- 1,541 ml of blood not drawn
“We’ve really tried to focus on the patient experience and tap in to why physicians got in to medicine,” said Josh Heck, MD, radiology resident and Co-Chair of the Vanderbilt Choosing Wisely House Staff Steering Committee. “Our message to our colleagues is to do the right thing for your patient, and we’re going to support you by providing information and feedback.”
The regular reports have helped residents understand how their performance compares to their peers and have increased the number of conversations happening at all levels of the organizations about what care patients really need.
“We approached this initiative as a cultural change, and I see it in interactions with other residents. We’re thinking more about what daily labs patients need and it’s coming up in conversations in the hallway,” said Dr. Iams. “I recently overheard an attending ask his residents why they were in last place and what they could do to improve.”
Members of the House Staff Steering Committee have given presentations to each of the specialty departments at Vanderbilt, as well as to administration. They are also seeking ways to embed Choosing Wisely in the organizational culture; for example, including it as a standing agenda item for resident conferences.
“The most impressive part of this initiative has been its ‘ground-up’ strategy – allowing the residents to tackle improvement initiatives that are meaningful to them, then working to communicate their successes to leadership in order to integrate their work into broader institutional initiatives while keeping the residents highly engaged,” said Donald Brady, MD, Senior Associate Dean for Graduate Medical Education and Continuing Professional Development.
Due to the success of the effort to reduce unnecessary lab tests, the committee plans to expand the model to other areas identified by the Choosing Wisely campaign as wasteful. Hospitalists, general surgeons and intensive care unit staff have all expressed interest in joining the competition.
“That’s what’s great about the Choosing Wisely campaign. We’re talking about unnecessary lab tests right now but this isn’t just about the labs – this is about providers making better choices and taking better care of their patients,” said Dr. Heck.