Demand optimisation in laboratory medicine: phase two report

2 Executive Summary 

Demand optimisation ensures optimal use of laboratory tests. This has a positive impact on patient experience, on healthcare outcomes and on laboratory budgets. Given the scope of these benefits, demand optimisation is a key priority in ensuring an effective healthcare system, in line with the aims of Realistic Medicine and the Healthcare Science National Delivery Plan.

However, looking at laboratory tests in isolation will not have the desired long term effect in ensuring a cultural change. Diagnostics is an integral part of the overall complex care pathway and as such a ‘whole systems’ approach will ensure that efficient and clinically effective pathways are designed; resulting in patients having the correct investigations, reducing waste and adding value.

In developing a strategy for demand optimisation, the key areas to consider are:

• Minimising over-requesting and under-requesting, both of which can be damaging to patient care
• Reducing unnecessary repeat requesting
• Ensuring appropriate and useful test repertoires are universally available across all healthcare outlets
• Standardisation of nomenclature/test coding to reduce unnecessary variation and allow automated data monitoring systems to extract laboratory test usage information in an efficient, consistent and timely manner
• Internal standardisation of laboratory practice – to ensure the optimal processes, procedures and testing protocols are adhered to.

The Scottish National Demand Optimisation Group (NDOG) was formed in 2015. During phase I, NDOG identified already existing demand optimisation work as well as undertaking a number of feasibility pilots to identify unwarranted variation, with a view to designing targeted interventions.

This report outlines phase II activity, which continues to develop the themes from phase I. This includes the full development of an Atlas of Variation (AoV) for laboratory test requesting covering multiple disciplines from the whole of Scotland.

Targeted static observations of marked variation from the AoV provides a starting point from which to develop interventions aimed at reducing unwarranted variation. An interactive, web based version of the AoV has also been developed which would allow a range of healthcare professionals to interact in a variety of ways that could identify and promote more appropriate test use. Work to develop a range of dashboards that focus on relevant requesting information for specific groups has also begun.

Within this report, significant examples of good demand optimisation practices, for potential wider roll out, have also been included.

There is a need to maintain the momentum from the initial successful phases of the national Demand Optimisation programme and implement improvement strategies locally and nationally, embedding the values and tools of demand optimisation into operational practice. 

To enable this, NDOG has made the following recommendations: -

1. Pilot the Atlas with referring clinicians: -

• to obtain feedback on the utility and identify improvements 
• to widely promote its capabilities in highlighting variation for demand management at individual, group and board level
• to provide full access to all to enable new and sustained improvements 

2. Focus on sustaining the current quality improvement initiatives, as well as delivering and monitoring new quality improvement (QI) proposals and progressing implementation of the ongoing proposals. This should be supported by the production of a QI package to instigate interventions in specific areas of unwarranted test requesting. 

3. Ensure alignment with the values of the Realistic Medicine and contribution to the Scottish Government’s vision for the future of primary care services. 

Phase III of the NDOG programme will begin in Autumn 2019 and will be focused on developing specific test ordering interventions aimed at promoting more appropriate testing and reducing unwarranted variation. Closer working with colleagues outside of laboratory services will also be developed, with a particular focus on developing partnerships with laboratory service users. 

The following objectives have been agreed for Phase III: -

• Engaging with referring clinicians to continue to improve the Atlas of Variation and promoting its capabilities within the GP community
• Data collection for the calendar year of 2018 to build upon the existing data collected in phase II
• Exploring alternative options to streamline data collection for populating the Atlas
• Where applicable, undertaking internal demand optimisation within laboratories to review and standardise methodologies 
• Monitoring and reporting on QI programmes being delivered
• Expanding stakeholder engagement by coordinating quality improvement champions at a local level to support change 
• Engaging with referring clinicians and laboratory managers to promote a cultural shift in managing requesting patterns
• Implementing interventions where unwarranted variation can be identified
• Continuation of clinical networks engagement at a national, regional and local level around specific conditions to develop and implement requesting guidelines which could be referenced at a board level
• Promoting demand optimisation and the realistic medicine agenda at conferences, in reports to professional bodies and in newsletters

The support of Scottish Government for the third phase is welcomed. This will enable the continued progression of NDOG aims through a partnership between laboratory diagnostics and service users.