In 2012, the Choosing Wisely initiative was commenced by the ABIM with numerous societies putting forward lists of overused tests or procedures. The Choosing Wisely movement has spread to numerous countries including the UK, Canada, and Australia. The movement has spurred 1000s of quality improvement projects worldwide. Improving utilization and/or efficiency in the laboratory includes: curtailing inappropriate laboratory tests from being ordered, electronically stopping unnecessary duplicate tests, automating manual processes, eliminating paper-based processes, implementing testing cascades, and curtailing unnecessary transfusions. Since the choice of quality improvement projects appears limitless, it makes it difficult to know where to get started! If you elect to address overuse of a common laboratory test, numerous avenues are available to assist you with narrowing your list: ask your clinicians which tests your hospital is overusing (they know!), look at variability of test use by clinicians within the same area, consult the quality improvement literature for analytes that others have addressed, and sift through the choosing wisely statements for items you have not addressed. There are also numerous system levers you can pull to bring utilization under control: education (grand rounds, screen savers on computers, alerts on the log-in page of your EMR or landing page for the hospital internet), computerized provider order entry controls, middleware controls allowing identification of duplicate tests, removal of overused tests from requisitions and ordersets, implementation of criteria for certain test types, and audit and feedback to high users. Evaluation of success should be measured in repeated quality improvement cycles of plan-do-study-act (PDSA). Never be surprised if your first attempt fails to improve utilization. Lastly, don’t forget to share your successes by publishing your results – this will assist with more rapid improvement in healthcare.
1. Identify areas of inefficiency in the lab that need improving
2. Identify tests that are commonly overused Evaluate system changes necessary to bring utilization down
3. Assess how to know if your system change was successful