Achieving Change at Scale
HCA Healthcare (Hospital Corporation of America) is one of the leading healthcare systems to address the problem of overuse in laboratory testing, targeting laboratory stewardship using a successful multidisciplinary approach to drive evidence-based care.
The organization reviewed its use of laboratory services three years ago, and found that, like many healthcare systems, they had a significant opportunity to improve test utilization. Of course, some divisions were doing better than others and the vast majority – 90 percent – of the testing was for hospitalized patients. This volume was projected to grow at more than three percent per year.
That is when Heather Signorelli, DO, chief laboratory officer at HCA Healthcare, came on board in the organization’s Continental Division to help build a laboratory stewardship program for test utilization. She achieved success in similar work at another health system, consolidating and standardizing lab testing practices across six facilities, but HCA Healthcare’s scale presented a unique lab challenge.
“We started lab stewardship within our Denver area hospitals and have now moved that onto all our hospitals in the U.S. We are sharing this process with our six hospitals in the United Kingdom as well, so they too can begin a laboratory stewardship program,” said Signorelli, noting that 12 physician subspecialties were represented on the first Laboratory Stewardship Committee (LSC), based in its Continental Division.
The hospitals’ Medical Executive Committees gave authority to the LSC to change test menus and order sets simultaneously in all Denver hospitals. One of the key partnerships has been with the Clinical Application and IT Department, which updated order sets, removed tests off the test menu and developed algorithms to help eliminate the possibility of duplicate testing, according to an internal report on the work. The team even began standardizing print numbers for test orders in electronic health record system across the Denver market.
To date, the Continental Division alone has seen a significant decrease in tests per average patient day.
“It’s a multi-specialty group of physicians who are leading the charge as the executive sponsors. These sponsors have helped integrate this work into the rest of the quality programs that we have at HCA Healthcare. Our division chief medical officer, Dr. Gary Winfield, heads the sponsor group. We have great integration with all our physicians, our nurses, our infection prevention folks. It is not just the lab driving this. We’ve empowered team members across clinical disciplines.” The system employs 94,000 nurses, with a total workforce of 270,000 plus.
Signorelli said it was a huge lift to get its 38,000 physicians engaged and on board with education, re-education and communication regarding Choosing Wisely overuse of diagnostic and other lab testing recommendations from the American Society for Clinical Pathology (ASCP). Since forming the LSC, the organization nearly eliminated obsolete tests and pioneered their own guidelines using algorithms and clinical decision support to reduce excessive lab ordering.
“We spent a lot of time working with physicians to help them understand the literature and to help them understand where we’re coming from, building the right medical leadership that could help drive this within the facilities in our division,” said Signorelli, adding that enlisting physician leaders as advocates was critical to getting physician input and addressing concerns.
“It’s really a new approach within the laboratory, advising physicians on what tests they should and should not order. You want to do that with a lot of physician input so it’s really a bottom-up approach and not a top-down approach. That gave us positive feedback,” she said.
The lab stewardship committee took on easy topics first, such as obsolete lab tests, to establish a good change-making process. From there, the committee has grown in scope to address issues that are more difficult. One such issue, genetic testing, accounts for most of HCA Healthcare’s anticipated lab services growth.
Working with the system’s genetic counselors, the LSC now requires all genetic testing to receive pathology or genetics team member approval; this ensures that the right test is done at the right time. HCA Healthcare has also created its first laboratory service line, which focuses on developing an infrastructure with division laboratory stewardship committees in all 15 divisions, within 184 hospitals.
Signorelli said the goal with the project was to achieve 50 percent reduction in volume by 2019 for obsolete/limited use tests. All but one of the system’s 15 divisions has reached the mark. Even within the outlying performers, all have achieved a 40 percent reduction, based on average patient days.
Signorelli was recognized as an ASCP Choosing Wisely Champion in 2018.
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