When the workflow planning team brainstormed the pre-examination phase of testing, they first looked at the test selection and ordering process. When they investigated if best practices in ordering were being followed, they determined that frequently ordered tests did not fit the diagnostic criteria for payment from Medicare and other insurance providers. This resulted in delays due to the need to inform the provider, who subsequently would need to change the order or provide a reason that the test was still needed so an exception could be requested. The patient also needed to be informed so they could decide if they were willing to pay for the test if their insurance provider did not approve it. This all created extra work for the laboratory staff and slowed down workflow. Perhaps most importantly, if inappropriate tests were being ordered, this could affect patient care. A second problem identified in this category was tests ordered by providers did not always get to the lab in a timely manner.
White Board Brainstorm: Provider Test Order Based on Best Practice
Problem 1
Test orders do not always match the payment code.
Five Whys:
- Why do test orders not always match the payment code? Because physician X often orders tests that do not match the payor's diagnostic codes? Reason: With the other physicians, this has not been a problem.
- Why doesn’t physician X often order tests that do not match the payor's diagnostic codes? Reason: Because X is an older physician who likes to follow old rules for assessing patient conditions through lab testing.
- Why does physician X not want to change to more modern thinking on test ordering? Reason: Because X lacks knowledge and trust in newer recommendations for testing.
- Why does X lack knowledge and trust in new recommendations for testing? Reason: Because X has not taken the appropriate continuing education to upgrade his skills in this area.
- Why has X not taken the appropriate continuing education (CE) to upgrade personal skills in this area? Reason: The CE has not been made available.
Suggested Solutions:
- Have colleagues encourage X to take CE to upgrade skills in this area.
- Provide CE in this area through online courses and offer to send X to a review course on lab test utilization and provider coding.
- Provide a laboratory information system (LIS) integrated with the hospital information system that the physicians can use to choose the correct tests that fit the provider payment codes.
Problem 2:
After the provider ordered tests, orders often did not get to the lab in a timely manner.
Five Whys:
- Why did test orders not get to the lab in a timely manner? Reason: The nursing staff responsible for getting the lab orders to the ward clerks to chart were slow in doing this, and the ward clerks were slow in charting the information and getting the orders to the lab.
- Why was the nursing staff slow in doing this? Reason: Nursing staff shortage on shifts causes them to prioritize tasks for best patient care.
- Why was there a nursing staff shortage? Reason: COVID patients had filled the wards.
- Why were the ward clerks slow in charting the test orders and getting the test orders to the lab? Reason: Overload of work for the ward clerks.
- Why was there an overload of work for the ward clerks? Reason: COVID patients had filled wards at 110% capacity.
Suggested solutions:
- Hire more staff on the wards if possible.
- Provide an integrated lab information system (LIS) that would allow the physician to order the test desired and have the order go directly to the lab and to the patient's chart.
