As clinical laboratories continue to experience pressures to lower costs and enhance performance in a resource-constrained environment, our need for data-driven tools to guide our operations is ever-increasing. In this setting, looking at solutions employed in other industries that face similar pressures to produce the highest-quality products at competitive price points can prove useful.
Benchmarking—the practice of measuring performance against a target using a specific indicator—is used broadly in other industries, especially manufacturing, to tackle these challenges. Indicators might include things like cost (how inexpensively can I deliver a product), productivity (how efficiently can I make something), or defect rate (how consistently can I make something). While benchmarking applications are relatively nascent in clinical laboratories, some studies have been published recently that highlight its promise (1,2,3). Given the similarities between clinical laboratories and the production of other goods, benchmarking represents a real opportunity for improving our stewardship activities.
Benchmarking Approaches
Benchmarking takes many forms. Process, or best practice, benchmarking is particularly relevant for clinical laboratory stewardship. In this model, one identifies processes and relevant best practices to establish target improvement goals. Performance in these processes is then measured against the target after the best practices have been implemented.
There are two main methods for establishing a target: absolute and relative. Absolute benchmarking makes comparisons based on guidelines. In this case, the indicator would be a lab’s performance relative to the standard of a guideline. This is a gold standard practice as guidelines provide accepted targets for performance comparison.
In contrast, relative benchmarking makes a performance comparison between groups and models the performance of industry leaders. In this case, laboratorians might look for comparisons within their own organizations or between organizations. For the former, this might involve assessing variation in performance among providers in selecting the correct laboratory test for an indication.
Relative benchmarking is useful in the absence of accepted guidelines. However, while relative comparisons reveal variation, they might not shed light on the appropriateness of a given practice. One organization might use less of a given resource than another organization, but what drives that practice or whether the practice contributes to better care delivery might not be clear. Some clinical laboratorians might have experience with relative benchmarking through initiatives like the College of American Pathologists’ Q Probes or a benchmarking service like Vizient.
Developing Benchmarking Targets
The process for developing and implementing a benchmarking initiative (Figure 1) shares a lot in common with the Plan-Do-Study-Act process improvement tool. The first steps are to select a process and identify a best practice, either in comparison to a guideline or some other group. From there, labs need to measure baseline performance for their current process and compare it to the target. When lab staff identify a gap, they can implement changes while continuing to measure performance. Multiple cycles of implementing changes and evaluating performance might be necessary to get to the target performance level. Once a lab reaches its goal, leaders can refocus resources and begin the cycle again with a new process.
Key Considerations
Several important considerations raise the likelihood of success when selecting a stewardship target amenable to benchmarking.
If Something Is Measurable, It Is Manageable
When a lab can measure its performance via an indicator, this gives the lab team a means to measure improvement. However, some things are inherently more measurable, and thus more manageable, than others. For example, the ABIM Foundation maintains useful guidelines for stewardship through its Choosing Wisely initiative (4). Recommendation 27 of the American Society for Clinical Pathology’s Choosing Wisely guidelines states, “Do not repeat hepatitis C virus (HCV) antibody testing in patients with a previous positive HCV test. Instead, order hepatitis C viral load testing for assessment of active versus resolved infection.” The volume of repeat HCV antibody testing is relatively straightforward to monitor and thus makes a good indicator for measuring improvement. Conversely, Recommendation 3, “Avoid routine preoperative testing for low risk surgeries without a clinical indication,” might be tougher to manage given the challenges in gathering data on whether a valid clinical indication exists for a preoperative order.
Exercise Caution When Basing a Target on Another Organization’s Performance
When comparing themselves to another group, clinical laboratories should choose peer organizations carefully. How similar or dissimilar one lab is to another might determine the appropriateness of modeling one’s performance against the other. For example, a lab seeking to benchmark its blood product utilization might want to choose organizations that have similar case complexity and similar scope of services, like running (or not) a transplant or extracorporeal membrane oxygenation program. In making comparisons against another organization, a lab would also need to ensure that both entities measure the same metric in the same way. For instance, if a metric involves units issued per day, both organizations need to measure patient days in the same way for a valid comparison.
Serve Patients Well and the Dollars Will Take Care of Themselves
This will be common wisdom to readers of Clinical Laboratory News, but labs’ first focus should be taking care of patients, with bottom line concerns following. Healthcare organizations optimize their value equation by increasing quality and decreasing costs. Clinical laboratories represent only approximately 3% of annual healthcare spending in North America (5). Accordingly, labs will do well to maximize our contribution to the quality of patient care instead of starting with the goal of reducing lab costs. Hospitals have relatively more opportunities to tackle the 97% of expenses incurred outside laboratories. Focusing on quality leads to better outcomes and lower expenditures for the total cost of care for our patients.
Challenges to Benchmarking Success
Common challenges with implementing benchmark initiatives include data liquidity (i.e. data availability) and organizational expertise in working with laboratory data to generate insights. Data analytics is expensive, so finding ways to demonstrate the value of investing in this resource through measured performance improvement is a great way to build momentum and support for additional resources. Starting small and building on those wins is a good practice to secure more investment in analytics resources.
Labs also face the challenge of hospital department budgets typically being managed in silos. Improved outcomes or cost savings through laboratory initiatives might create wins for stakeholders outside a clinical laboratory but not the lab itself. Don’t be afraid to share those wins with others while simultaneously promoting the lab’s contributions to those successes. Collaboration allows all parties to win while keeping patients at the center of the effort.
Final Thoughts
Benchmarking provides a powerful resource for labs to confront the performance and cost pressures they face today. Focusing on good clinical practices with measurable indicators of performance provides a solid practice to improve the value of laboratory services to our patients.
References
- Signorelli H, Straseski JA, Genzen JR, et al. Benchmarking to identify practice variation in test ordering: A potential tool for utilization management. Lab Med 2015;46:356-64.
- Rudolf J, Jackson BR, Wilson AR, et al. Organizational benchmarks for test utilization performance: An example based on positivity rates for genetic tests. Am J Clin Pathol 2017;147:382-9.
- Hueth KD, Jackson BR, Schmidt RL. An audit of repeat testing at an academic medical center: Consistency of order patterns with recommendations and potential cost savings. Am J Clin Pathol 2018;150:27-33.
- Choosing Wisely. ABIM Foundation. http://www.choosingwisely.org/societies/american-society-for-clinical-pathology (Accessed February 5, 2020).
- Examining clinical laboratory services: A review by the healthcare fraud prevention partnership. https://hfpp.cms.gov/hfpp-white-papers/hfpp-clinical-lab-services-white-paper.pdf. (Accessed February 5, 2020).
Joseph Rudolf, MD, is an assistant professor and director of laboratory medicine and pathology informatics at the University of Minnesota and the laboratory medicine and pathology chief medical informatics officer at Fairview Health Services in Minneapolis, Minnesotta. +Email: [email protected]