Clinical laboratory testing is integral to the delivery of health care, as a significant amount of medical decisions are influenced by the results of laboratory tests. The Canadian Agency for Drugs and Technologies in Health writes, “There are examples of initiatives and strategies aimed at optimizing laboratory utilization across Canada and around the world; however, few mechanisms are in place to promote awareness of such initiatives.”9
We need to promote the hard work labs are doing, directly and indirectly, to support appropriate test and procedure utilization. Here are some examples of work that has been conducted recently.
Let’s celebrate your workplace and how it contributes to
improving the utilization of laboratory tests and procedures in Canada!
At the annual CSMLS LABCON, we try to highlight relevant laboratory utilization projects that relate directly or indirectly to the Choosing Wisely Canada recommendations. Here are a few that might interest you.
In the “Becoming Stewards of Our Laboratory Resources” article series, written by Amanda Van Spronsen, featured in the Canadian Journal of Medical Laboratory Science (CJMLS), we examine the efforts and results of medical laboratory professionals tackling inappropriate laboratory test utilization.
Building a Culture of Resource Stewardship at Bluewater Health
The University of Alberta and the CSMLS have been collaborating on a project called Lab Wisely to explore medical laboratory professional (MLP) involvement in initiatives to improve the utilization of health care resources. Our activities to date include the formation of an expert panel to develop recommendations and a national survey, select statistics from which you will find in our new article series.
This article is the first in a Lab Wisely series that highlights laboratory utilization projects across Canada. In this article, we outline our conversation with Debbie Croteau, medical laboratory technologist (MLT) and Director of Diagnostic Services at Bluewater Health in Sarnia, Ontario, to learn about the success of Choosing Wisely initiatives at Bluewater Health.
HOW IT ALL STARTED
In 2015, Debbie Croteau and a small group of colleagues from Bluewater Health took a leadership course through the World Health Innovation Network. They were challenged to find a project for the course, so the group chose to focus on Choosing Wisely Canada. They wondered how it could be put into effect at their institution, and this led to the development of the Choosing Wisely Committee at their 300-bed hospital in Sarnia, Ontario. Four years later, they now have an expanded, engaged and diverse committee, along with a list of successful initiatives that have improved the appropriateness of care in their institution. It is well known that some laboratory tests are prone to inappropriate use, and many institutions are trying to tackle overtesting — an issue that became Debbie’s focus. Debbie and her colleagues drew inspiration from Toronto’s North York General Hospital, which addressed high-volume testing and found success after they focused on reducing requests for ten specific tests. At Bluewater Health, they decided to focus on their “Top 7” lab tests, targeted for improved utilization: blood urea nitrogen (BUN), aspartate aminotransferase (AST), thyroid stimulating hormone (TSH), erythrocyte sedimentation rate (ESR), serum folate, creatine kinase (CK) and urine cultures. Many of these low-value lab tests existed on prearranged test bundles that were automatically ordered together.
The committee approached the issue by first providing physicians with evidence about test misutilization before shifting to more specific Bluewater Health objectives. Then, they made a clear request: Would the physicians consider removing the “hard check” (the automatic ordering option) for these tests on their order sets? By priming the doctors with evidence about the potential for overuse, physicians were more open to reconsidering their practices. As a result, the “Top 7” tests were unbundled from many order sets, and testing dropped dramatically. Serum folate testing alone dropped by about 94 percent, and BUN testing dropped by 74 percent. Credit for the success, says Debbie, goes to Choosing Wisely Canada for making high-quality, credible evidence readily available for distribution.
Though a team approach to address overtesting is important, gaining physician buy-in and participation is critical due to their influence and role in test ordering. In addition to filling physician committee positions, such as committee chair, something that the staff at Bluewater Health focused on was providing venues for physician peer-to-peer interaction. Debbie described a time when the committee presented Choosing Wisely recommendations about blood transfusion to surgeons and anesthesiologists. They noticed that by allowing open discussion time, the physicians began to compare practices while sifting through the evidence, helping one another understand how to implement the new recommendations. A year later, ordering single units of blood, as opposed to habitually ordering multiple units, had become second nature. The physicians have also been engaged in other ways. They are encouraged to create “tips of the month” that are circulated broadly, and they deliver presentations about improving resource utilization to other health care professionals, such as physiotherapists and chiropractors. By putting Choosing Wisely on as many agendas as possible, it is becoming part of the culture of the organization.
VALUE FOR MONEY
Much like creating a brand, making key messages clear can be helpful when you are trying to get buy-in. The message that Bluewater Health’s Choosing Wisely Committee wanted to convey was that it wasn’t just about saving money. It was about improving care and doing “what was best for the patient,” as Debbie states. While a full cost analysis wasn’t performed, approximately $50,000 per year was saved just on laboratory testing by modifying the order sets. This also provided an opportunity — the savings were put towards higher-value tests that physicians requested, such as brain natriuretic peptide (BNP). The opportunity to tell stories like this went a long way in gaining vital support from upper administration.
THOUGHTFUL COMMITTEE COMPOSITION
Another component of success was the effort to expand beyond the four founding members of the Choosing Wisely Committee. They sought to diversify in order to bring in new perspectives. In addition to a variety of health professionals, the committee now has business directors, communications specialists and a patient experience advocate. Subject matter experts are often included for short stints on specialized projects, such as the Charge MLT for blood banks when the committee addressed transfusion recommendations. The committee also includes many physicians for short-term efforts. By encouraging brief but intense participation times, the committee can gain insight from relevant voices as well as capitalize on energy and momentum before it wanes.
ADVICE FOR MLTs AND MLAs
Debbie acknowledges that she is often the sole representative of the lab on the Choosing Wisely Committee. Shiftwork can make it difficult to attend regular meetings, so ensuring the lab has a voice requires intention. While in the lab, team huddles to discuss utilization initiatives are vital, as MLTs and medical laboratory assistants (MLAs) can offer insight and feedback into ordering and testing patterns. Being aware of local initiatives may reveal opportunities for lab professionals to support work that is already going on. Data collection and analysis is always important to ongoing efforts, and falls within the skill sets of many lab professionals. At Bluewater Health, the contribution of one of the MLAs who initially helped with collecting data on transfusion practices was so valuable that the activity is now a protected part of her job. For one half-day every month, she compiles and analyzes data to support the sustainability of the utilization initiatives. Debbie also stresses that it’s important to be aware of broader campaigns and recommendations, as well as the evidence supporting best practices in utilization guidelines. By having this knowledge, MLTs and MLAs are better prepared to raise questions about the ordering practices that they are observing.
Much can be learned from the Choosing Wisely story at Bluewater Health. Factors contributing to their success include sharing available evidence in thoughtful and diverse ways, engaging physicians, focusing on meaningful outcomes beyond cost savings, being intentional and proactive about committee membership and harnessing existing strengths of the health care team. Laboratory professionals can and do have a role to play in realizing the more efficient use of health care resources, particularly if they express interest and secure the lab’s role in implementing solutions inspired by Choosing Wisely. Does your institution have a Choosing Wisely Committee? Do you have a venue to talk about laboratory test utilization issues? Ask around and see — you might become instrumental in building a culture of laboratory resource stewardship where you work!
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Improving Transfusion Practices in Manitoba
The University of Alberta and the CSMLS have been collaborating on a project called Lab Wisely to explore medical laboratory professional (MLP) involvement in initiatives to improve the utilization of health care resources. Our activities to date include a national survey and the formation of an expert panel to develop recommendations. This is the second in a Lab Wisely article series that highlights laboratory utilization projects across Canada. In this article, we outline our conversation with three individuals from Shared Health Manitoba who participated in a recent project: Christine Peters, project manager; Hayley Johnson, communications specialist; and Darcy Heron, medical laboratory technologist (MLT) and technical director for Transfusion Medicine.
Shared Health is Manitoba’s provincial organization responsible for the coordination and delivery of health services. Choosing Wisely Manitoba, which originated as a partnership involving Shared Health, was the earliest provincial initiative to join the broader Choosing Wisely movement. This has created an opportunity for laboratory services in Manitoba to participate and collaborate in interdisciplinary, province-wide initiatives. The following recent example is a project related to a specific lab utilization issue in transfusion medicine.
“Just One” Campaign
The utilization of red blood cells (RBCs) for transfusion is the topic of more than one Choosing Wisely Canada recommendation. Several societies have recommendations against transfusing too much or too soon, such as those for critical care medicine, internal medicine, palliative care and others. While data analysis showed that Manitoba is among the highest per capita user of RBC transfusions, Alberta and Saskatchewan had both undertaken successful RBC utilization improvement projects. With lessons available from their neighbours, addressing RBC overuse in Manitoba appeared to be a relatively easy goal to reach. Shared Health Manitoba’s “Just One” campaign was launched in 2018 and began with clinician awareness. Informational postcards about the importance of ordering “Just One” RBC unit at a time to reduce the waste that can occur with potentially unnecessary extra units were attached to each blood unit. As it was an educational initiative, this step did not create much concrete change, but it was an important step to raise awareness of the issue. The next step of the campaign was to make changes through policy by enacting new guidelines based on hemoglobin levels in stable, non-bleeding patients.
Laboratory Staff as Gatekeepers
Transfusion medicine is a unique discipline within the laboratory. It isn’t just about testing because there is the added activity of product issuing. The new transfusion guidelines from the “Just One” campaign targeted reasonably stable patients, meaning the new criteria do not apply to requests from areas such as the emergency room or intensive care unit. For all other requests, the laboratory staff are asked to consider hemoglobin levels before issuing an RBC unit. For levels 70 g/L or less, one RBC unit is issued right away. Between 71-80 g/L, the laboratory staff still issues the unit, but a hematopathologist may follow up with the ordering physician the next day to review the request. If the hemoglobin is 81 g/L or greater, the laboratory staff calls the ward to inform them that the RBC units will not be issued and refers them for follow-up with the hematopathologist. Throughout this phase of the campaign, the project team was very hands-on, making sure that everyone understood the new guidelines. Laboratory staff were involved in creation and pilot-testing of new product request forms. As the technical director, Darcy was right there with her front-line staff to provide opportunities to respond to questions and concerns. She believed it was important to talk with her staff about how the changes may affect them. As the project manager, Christine helped coordinate the overall training and education initiatives, due to the vast number of health care professionals involved.
A Team Effort
A common thread with large scale projects is the need for broad engagement and support, and the “Just One” campaign leaders used teamwork and communication to do so. Choosing Wisely Manitoba developed a process for getting buy-in that they use across their projects; in short, they start with the highest levels and then fan out. A core project team is formed and tasked with creating a broad interdisciplinary team that includes front-line workers. For the “Just One” campaign, the core team includes representatives from transfusion medicine diagnostics, Best Blood Manitoba, hematopathologists and operations directors. Frontline groups include ordering physicians, nurses and laboratory staff. Administrative staff also have key roles to play; for example, one essential role is that of the communications expert. All three of the Shared Health Manitoba interviewees emphasized this point. Communication is paramount at all stages, from buy-in to development, and throughout implementation and follow-up. As the communications specialist, Hayley mentioned the importance of face-to-face interactions. For all sizes of projects, she recommends getting the project goal on as many agendas as possible, as early as possible, and trying to be there in person.
Advice for MLTs and MLAs
Most MLTs and medical laboratory assistants (MLAs) have a unique perspective on how well projects are being implemented at the front line. Project members who spend more time in an office aren’t privy to this type of information. Darcy recommends that “if you see something, let people know. Aim to be that team member who is willing to provide constructive feedback on new processes coming down the line.” All health care workers have contributions to make if they are engaged and observant about their jobs. According to the Shared Health crew, being aware of challenges that exist within the health care system and aligning these with improvement opportunities is a valued characteristic. Christine, the project manager, believes there are often many opportunities to get involved with an improvement team, given the constant need to respond to changes in the health care system. The desired type of team member for the job is collaborative, establishes good working relationships both within and outside of the lab, actively looks for ways to improve processes and provides suggestions positively. Ultimately, MLTs and MLAs need to have a level of self-motivation to hunt down opportunities and start talking to people, particularly in other professions, about getting involved. Laboratory managers and supervisors also can play a role in encouraging these opportunities by creating an environment that fosters employee development and growth.
In a system-wide project, there are many moving parts that require coordination at a high level. The running theme in this type of work is that communication is key, and it takes an entire community to make meaningful change. Becoming involved in large interdisciplinary initiatives may be out of the comfort zone of many laboratory professionals, or they may feel helpless in knowing how to get started. The staff at Shared Health Manitoba emphasized the importance of relationship building and networking, both of which take time, effort and intention. It’s also important to appreciate that health care is a complex environment. Developing an understanding of the pressures and trends in the broader system and allowing that to shape feedback about areas of improvement emphasizes a willingness to work with a diverse team.
Capitalizing on Change at Yukon Hospital Corporation
This is the third article in our Lab Wisely series that explores experiences of medical laboratory professionals across Canada as they participate in initiatives to improve the utilization of health care resources. We talked with Sheri-Lynn Heighington, former core lab lead supervisor and interim manager at Yukon Hospital Corporation (YHC) to learn about two specific projects undertaken by YHC and the efforts made to build and sustain a culture of teamwork.
Change is difficult. It forces us to break old habits and learn new ones, which can be uncomfortable. The medical laboratory is characterized by rapid change, perhaps more so than many other areas in health care, and the staff at YHC are no strangers to this concept. YHC has undergone some sweeping changes in recent years, from updating physical spaces to improving quality of lab results. However, YHC staff went beyond simply making these changes to implementing some great strategies to help staff adjust to change. Sheri-Lynn’s experience within these processes highlights the importance of working on teamwork and trust amidst an ever-changing environment.
PROJECT #1: A NEW EMERGENCY DEPARTMENT
After years of planning, construction of a new Emergency Department (ED) at the Whitehorse General Hospital was completed in 2018. Hospital staff saw the new and updated space as an opportunity to improve on past processes and flows, including optimizing laboratory test utilization. To examine this opportunity further, staff formed a committee which included the lab quality manager, the laboratory information system (LIS) specialists, lead medical laboratory technologist (MLT), physicians from both the ED and the operating rooms, and administrative staff. Per the committee’s recommendations, ordering panels were adjusted to improve utilization and efficiency. For example, Urine Drug of Abuse screen was added to the ED Coma panel orders to ensure comprehensive and coordinated lab testing for this patient population. Additional standardized mass transfusion protocol panels were created to support subsequent orders. These changes were a result of consultation with affected stakeholders with a view to improving patient care while ensuring appropriateness of ordering practices.
The newly built ED also led to another opportunity: What could happen with the old space? The ultimate decision was to redevelop the space to be a new outpatient laboratory, so a redevelopment committee was formed. Laboratory staff were engaged and participated on this committee to provide input on the functional flow and layout of the space. They made a commitment to improve patient experience in privacy and confidentiality, efficiency and infection prevention and control. Laboratory staff were given the opportunity to tour other outpatient laboratories to observe examples of workflow possibilities. Their input directly shaped the new design. Engaging with staff early in the process amplified a sense of ownership and investment in the project; they were able to enjoy their new space and take pride and credit for their participation in making it all happen.
PROJECT #2: IMPROVING MICROBIOLOGY TESTING QUALITY AND SUSTAINABILITY
Rapid changes in microbiology technology and standards coupled with relatively low sample volumes meant that YHC, like many smaller laboratories, struggled with sustaining highquality microbiology services. A multidisciplinary team was assembled to explore options for improvement. The team consisted of medical directors, local hospital administration, the laboratory manager, the Quality MLT, hospital information system staff and physicians. After multiple meetings, the team made the decision to consolidate microbiology testing to YHC’s laboratory services partner in Vancouver, British Columbia. Working out the logistics took many months of regular meetings, exploring different transportation options and planning for staff retraining. Finally, the YHC team was ready for their multi-phased project launch.
To ensure the project was a success, the team developed an ambitious implementation plan to monitor the move of microbiology tests. Turnaround time, cost-effectiveness, and other quality indicators were measured every 30 days. These metrics were reviewed regularly, and plans were adapted for continuous improvement. A major hurdle to overcome was the communication of laboratory results. At first, there was no direct information system link between Yukon and British Columbia. Results needed to be uploaded from Vancouver to local Yukon servers or faxed. They experienced delays when results would occasionally get stuck in middleware. Eventually, all the kinks were ironed out for a new shared laboratory information system, and results were available in real time. Four months into the project, they achieved one of their primary goals: to ensure that the turnaround times were just as good as before, or better. An outcome worth celebrating was their ability to consolidate their microbiology testing without losing any staff positions within the laboratory. There were other positive changes, such as an increase in testing from rural sites. Physicians always had access to testing but would often experience delays receiving results. In the past, physicians were frequently asked to resubmit the sample because it was no longer viable once it got to the laboratory. However, the new sample format for sendout testing in Vancouver was considerably more stable. Once testing was moved to British Columbia and physicians started receiving quality results in good time, they were able to treat their patients more effectively. While improved microbiology test utilization was not the primary driver of this project, it was another important outcome.
OPPORTUNITIES FOR IMPROVEMENT
By all accounts, this was a successful project that continues to benefit patient care. Unfortunately, communication and engagement with the laboratory staff did not occur as planned, which ultimately resulted in significant loss of trust. Information about the potential change ended up in the public domain before any decisions were made. Some staff did not support the change, further complicating the situation and making it more difficult for YHC to effectively address the team. In the end, the laboratory staff were engaged as planned and their input was used in assessing options. However, by this time the damage had been done. Trust was broken and it would take a great deal of time and effort on everyone’s part to rebuild.
An integral step toward regaining trust was the recruitment of an independent team engagement consultant. She met with each staff member individually to hear their concerns and met with the entire team to create a strategic plan focused on improving morale and teamwork. To complement this work, project and laboratory leadership focused on maintaining a bidirectional flow of information. They set consistent and structured all-staff meetings and supportive team-building events. An early challenge in the project was staff scheduling and task changes. Working together, solutions were found to alleviate the scheduling pressures and challenges. Another outcome was the creation of training documents and new work distribution plans. MLT and medical laboratory assistant (MLA) participation was needed for these accomplishments, but because of the initial lack of trust, outcomes like these were delayed and more contentious than originally anticipated. Sheri-Lynn admits that there is still a way to go on the path to regaining trust, but the new laboratory leadership remains committed to transparency and teamwork.
INVESTING IN TEAM-BUILDING
The microbiology lab project revealed existing deficiencies in the team environment. The challenges experienced prompted leadership to find ways to foster a change-ready mindset and cultivate a well-functioning team. As part of this plan, they encouraged individual accountability for creating a positive working environment, since bottom-up approaches enhance buy-in and sustainability. Another part was demonstrating investment in this goal by contracting an independent consultant to support their recommendations. Team-building is not a single event. It’s a continuous improvement strategy that can reap many rewards when it’s woven into the fabric of an organization.
ADVICE FOR MLTs AND MLAs
There are lessons from this story for multiple levels of laboratory staff. Managers and supervisors should be aware of the ramifications of delayed staff engagement and fulsome communication. In the first project, staff engagement and change management went relatively smoothly. In the second project, there were a few bumps. It was vital to get input from microbiology staff to design a new way of handling the limited amount of testing that was still required on site, like STAT gram stains or C. difficile identification. The project team also needed to understand the new needs of the core lab where there would be more events during the day. If seeking this input comes too late, even inadvertently, it can be an uphill battle to obtain. Sheri-Lynn emphasized that communication that keeps everyone in the loop is vital, as is having a plan ready to be able to nimbly react if this is disrupted.
For bench-level MLTs and MLAs, an openness to change, and being an active partner in change, is important. However, when change comes unexpectedly, it’s much more difficult to handle. Naturally, it can feel like trust is broken. In these situations, trying to understand all perspectives and being willing to ask questions goes a long way. Starting with the assumption that people try to do their best is sage advice in many circumstances, including here. Although it can be difficult, focusing on the positive aspects of the change can help with a sense of willingness to work together. For all levels of laboratory staff, exerting effort to maintain teamwork and collegiality can help create resilience in challenging times.
No matter the size of a change management project, early, regular, intentional and transparent communications are paramount. Positive change starts with each individual and has the power to transform entire systems – as seen in the YHC laboratory. Despite some significant changes in recent years, the YHC laboratory is now a more engaged department, where ideas are exchanged fluidly, they celebrate their successes and laughter and trust fill the space. As a group, they are better equipped to deal with the inevitable changes that are a part of health care, and, as a result, are resetting the bar for other laboratories and hospital departments.
In addition to the CJMLS article series, we are gathering success stories from labs like yours! As part of a research practicum course, medical laboratory science students from the University of Alberta have been documenting the experiences, evidence and outcomes of projects from across Canada. Once these are compiled, we will post them and invite you to take a moment to read what they have found.
If you have a success story you would like to share, please contact email@example.com with information about your project, the outcome and lessons learned.
We are searching for passionate medical laboratory professionals to get the word out about appropriate laboratory test and procedure utilization. As a CSMLS volunteer or independent professional, you will find opportunities to tell people about the Choosing Wisely Canada recommendations for MLPs, as well as the vital role MLPs have as knowledge agents and advocates of appropriate resource utilization. If you require assistance, CSMLS will support technical resources to arrange and deliver a presentation.
Let us know how it goes! We welcome your enthusiasm and honed presentation skills, and we would love to hear about your presentation and who the audience is.
For more information, please view the application form. Contact firstname.lastname@example.org with your questions and comments.