Benchmarking cuts lab utilization nearly in half
Key is turnaround in practices, attitudes
Once upon a time in the good old of days of fee for service, no financial incentive existed for ordering fewer laboratory tests. But in today’s move to a prospective payment system, a facility’s ability to reduce and control the number of lab tests per patient is an important weapon in the managed care survival kit.
"It requires a new ordering system based on a 180-degree turnaround in practices and attitudes," says Linda Chambers, MD, medical director of transfusion services at Children’s Hospital in Columbus, OH. Chambers spearheaded a three-year initiative that cut the lab tests per adjusted discharge nearly in half.
At 70 tests per discharge, the 313-bed facility is ranked as one of the poorest performers among its peers, according to a database called Benchmark-ing Effort for Networking Children’s Hospitals, facilitated by Medical Management Planning (MMP), a consulting firm in Bainbridge, WA.
"The rate [of testing volume per case] was so high we had to scale back the graph before presenting it," says Sharon Lau, MMP’s consultant. That came as no surprise to Chambers.
"Everything the literature said was inefficient, we were doing," she says. "Not only did we allow standing orders, but we also had a very informal physician ordering system that had never been evaluated or examined. We had countless numbers of panels, profiles, and work-ups that had just evolved and codified over the years." And worst of all, they could be ordered with just one keystroke on the hospital’s ordering system.
So Chambers, along with a team consisting of the clinical medical director, senior administration, and the chiefs of medicine and surgery, as well as representatives from radiology, pharmacy, and laboratory, set out to build an ordering system more congruent with the demands of managed care.
First, Chambers needed to identify which clinical services were the highest users for raw numbers of tests as well as which clinical areas had the highest intensity of test volume.
To track the attending physician and the patient location at time the testing charge was incurred, she built a special parameter into the current ordering system that also would appear on the billing data base. She took data from six different sources in the hospital’s information system and loaded into a Lotus spreadsheet such patient demographic variables as admission, lengths of stay (LOS), clinic visits, inpatient test number and mix, and daily census. The result was a five-year picture of lab tests per patient day.
"We found that while the fact that average lengths of stay have shortened over the years from six to four days, the intensity of testing [tests per day] remained the same," she says. "We wondered if the shorter LOS might have resulted in more intense pattern of ordering tests. But the utilization picture looked exactly the same if LOS was taken into consideration."
A little psychology
To the team, that was a signal that changing the number of tests per discharge meant confronting two issues: an ordering system that addressed "basic tenets of human behavior" and mechanisms to reduce LOS, such as the 20-plus clinical pathways now in various stages of implementation.
"To truly affect utilization rates, we knew we had to build a system that would make it easier to do the right thing," she explains. For example, instead of automatically checking off a panel of tests on the first screen, the new order system would begin with discrete tests and require physicians to click through three or four screens to locate panels. "Because we knew that these large groupings of tests in panels and profiles were the No. 1 cause of high utilization, we also wanted to control and limit how many times a physician could exercise those options," she says.
In addition to mandating discrete orders, the new system delineated accountability. "Attending physicians are now responsible for every test that is ordered. And all orders have to be documented clearly using approved abbreviations."
Chambers explains why: As part of the team’s investigation, members examined certain charts of patients the data had pinpointed as high users of lab tests. "We found that some of the problem was due to ambiguous orders such as liver function tests’ that were transferred to the order entry system by a unit clerk or other third party," she says. "That person ordered more tests than necessary because she had no way of knowing if a liver function was three tests or 10 tests."
Such pronouncements are usually easier said than done, but in Columbus’ case, the facility was facing major revenue implications under managed care, and physicians were feeling vulnerable. "This timing helped us to change physician culture. Remember that physicians are wedded to our time-honored abbreviations. They’re our shorthand, our magic words. Now, with the new code under way, doctors do have to slow down and pay more attention, but it’s a way of reminding us that we need to make a conscious decision every time we’re about to spend the hospital’s money."
Chambers also emphasizes the importance of using data to help convince physicians of the need for change "Let the numbers speak for themselves," she says.
Encourage buy-in
Next Chambers worked to lower utilization rates for those high-intensity areas such as the intensive care unit and neonatal and hemo- oncology departments. Again she used data reports that tracked numbers of tests per patient day. "For example, we knew how many CBCs [complete blood counts] they ordered historically, how many by season, and the average number for three years," she says. "At first [the unit managers] said they couldn’t be ordering that many tests, but then they looked at the numbers."
Then, the medical director set a "generous test budget" for each department.
"We didn’t tell them how to reduce the budget for several reasons," she says. "One, we wanted to localize the responsibility for contributing to a solution to the overall problem of high utilization. Two, we understood that front-line staff were in a far better position to identify their problems and solutions than we were."
Chambers and the team also realized that the root cause of high utilization may be different in each department. "In some, the problem was standing orders. In another it may be keeping track of orders, and in still another it could be a case of too many players what the intern doesn’t think of, the resident does," she explains.
The intensive care unit, for instance, tackled its problem by reevaluating standing orders. "Before, they automatically ordered blood gases twice a day. Instead of basing all patients’ needs on the sickest ones, they now order tests based on each individual patient’s condition," she says.
[Editor’s note: For more information, contact Linda Chambers, MD, Medical Director of Infusion Service, Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205. Telephone: (614) 722-5301.]
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