Reducing Healthcare Variation – Requires Collaboration Between Laboratory Professionals and Providers
R. Keith Laughman
Mayo Clinic Emeritus Staff | Collaborating with Health System Leadership and Clinical Laboratory Leaders to Unleash the Clinical Laboratory of the Future
By?Les Wold, MD, MS, MBA and R. Keith Laughman, DBA (abd)
Analogies of healthcare to sports teams or an orchestra are common. If healthcare is an orchestra, then providers are the concert masters. Providers lead the activity in many ways. They initiate orders for diagnostic services and can set the tenor of the entire patient experience. However, considerable variation in test ordering patterns exists between providers today. Therefore, engagement between laboratory professionals and providers is critical to reduce this variation and harmonize care delivery for patients and the rest of the healthcare team.
But how do you effectively engage providers?
Don Goldmann, M.D., the chief medical and scientific officer at the Institute for Healthcare Improvement, has identified seven ways to engage clinicians/providers.*
Roughly translated, these seven are:
Efforts to reduce diagnostic variation critically rely upon provider engagement. Providers are in control of the diagnostic process, and hospitals need to engage them to reduce the diagnostic variation that leads to care variation and the associated downstream costs for the hospital and potentially less desirable patient outcomes. If we used Dr. Goldmann’s rules, what would that look like?
Rule #1 - A problem statement that frames the issue in language the provider can relate to could look something like:
The incidence of hyponatremia in our hospitalized patients is currently 17%.?Patients who experience a hyponatremic event while in the hospital have higher morbidity and mortality and a longer length of stay. This contributes to poorer clinical and financial outcomes. What can we do to reduce the negative consequences of hyponatremic events in our hospital?
Such a statement helps focus the issue on what matters most to providers (i.e., clinical care). It also lays out the financial implications (Goldmann rule #5) and avoids jargon (Goldmann rule #2). But how do you address Goldmann rule #4 and meet providers where they “live”?
Accommodating providers’ schedules is a critical part of effectively engaging them. Face-to-face meetings are challenging to arrange and frequently get delayed as competing demands pull the provider in a different direction. Fortunately, we have found that many initiatives supporting improved clinical and financial outcomes can be enabled through appropriately structured asynchronous conferencing approaches, allowing providers to participate when and where they have the time to do so. The use of such tools enables better provider engagement.
Goldmann rule #6, pertaining to relevant data, can also be accommodated, particularly regarding the use of clinical laboratory services. Clinical laboratories contribute approximately 70% of the objective data upon which providers make diagnostic and treatment decisions.
Data from the electronic medical record, laboratory information system, or billing system can be presented in such a way as to illustrate the relevant, local variation in ordering patterns. For example, variation in the use of clinical laboratory tests for the most common admitting diagnoses at a community hospital are illustrated in the following graph.
The red bars show the total number of unique tests used for each admitting diagnosis cohort, and the blue bars show the average number of unique tests per patient episode for that specific cohort. The dramatic difference noted in this simple bar chart immediately gets the attention of and engages providers to ask the question “Why?”
Goldmann rule #7 — show how the activity relates to provider goals — can be accommodated within the framework of the problem (in this example, showing how addressing hyponatremia can positively impact clinical and financial outcomes).
The data for a 300-bed acute care hospital illustrated above identified roughly 890 inpatients/yr. with two or more low sodium values. The average LOS for patients with low sodium in this data set is 9.3 days, while for patients without low sodium, the length of stay is 6.7 days. The Impact is greater than 2,314 hospital days/yr consumed.
If patients have a shorter hospital stay, they are more satisfied, and the hospital is better off financially, given the transition to more bundled reimbursement payment models. In addition, with an appropriate diagnostic pathway, providers will have a more predictable care pathway to share with patients and families.
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If the hospital is an orchestra, then providers, as the concert masters, play “first fiddle.” Engaging them to play from the same musical score concerning clinical laboratory diagnostics will help to ensure that the hospital plays beautiful music in this critically important aspect of medicine.
*Footnote “What Are Seven Ways to Engage Clinicians in Quality Improvement?” Institute for Healthcare Improvement Open School video, 06:50, https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/RulesForEngagingCliniciansInQI.aspx
Additional Reading
About Les Wold M.D
Dr. Les Wold has held numerous healthcare positions during his more than 40-year career as a member of both not-for-profit and for-profit organizations. During his tenure at Mayo Clinic, he was chair of the Department of Laboratory Medicine and Pathology, chair of Mayo Medical Ventures, chair of Mayo Collaborative Services, Inc., and a member of the Executive Committee and Mayo Clinic board of trustees. In all of these roles, he focused on diagnostic optimization and care coordination across the continuum to ensure that the patient’s needs came first. This focus has reinforced his belief that data-driven decision-making and the use of tools such as diagnostic pathways, reflex testing protocols, and effective alerts generated by the clinical laboratory are an essential part of improving care delivery for patients and providers.
Dr. Wold has had an abiding interest in leveraging data to better support the needs of patients and providers. He has encouraged the participation of all stakeholders in the dialogue to develop better systems of care. He has focused his efforts on how clinical laboratories can coordinate care across the continuum, from acute hospital care to care at home or in skilled nursing facilities, and ease providers’ administrative burden.
About Keith Laughman
Keith Laughman?is the Founder and Managing Partner at?CareTinuum Advisors?and CEO of InSyncDx Solutions, Inc. Laughman brings more than 30 years’ experience in the lab business, including a 15-year term as President of Mayo Medical Labs. Following Mayo, Laughman became President of AmeriPath Reference Services and Specialty Reference Laboratories. Laughman later helped to create and served as President and CEO of the reference lab startup Med Fusion (Dallas/Fort Worth). Both AmeriPath and Med Fusion were later sold to Quest Diagnostics. Laughman also served as EVP of Community Care Solutions at SunQuest Information Systems and CEO of Viewics Analytics Solutions.