With rising healthcare costs, the appropriate use of laboratory testing is becoming increasingly important, as over- and under-use of laboratory resources can create a burden on both staff and the entire healthcare organization. 

Platelet disorders, von Willebrand disease (VWD), and hemophilia are among the most common bleeding disorders in Saudi Arabia, and routine laboratory testing for hemostasis and thrombotic disorders is of great importance. Basic tests include thrombophilia tests, such as chromogenic factors. In addition, coagulation factors 1–13 may be deficient, which in some cases may affect the intrinsic or extrinsic pathway, or both, and require testing. However, overuse of clotting factor tests without justification or consultation with a hematologist may increase unnecessary requests for laboratory testing, patient dissatisfaction due to frequent blood draws, and wasted resources in medical centers.

This background and international evidence served as the rationale for a quality improvement research project at a tertiary care facility in Saudi Arabia, where the hematology clinic sees over 3,000 patients and receives 500 new referrals annually. An internal audit conducted in 2021 found that up to 89% of coagulation and chromogenic factor tests were requested unnecessarily. Thus, the quality improvement research project was initiated to reduce requests for unnecessary laboratory tests by implementing a Plan-Do-Check-Act (PDCA) project, thereby improving the efficiency and productivity of laboratory testing based on the SMART (Specific, Measurable, Achievable, Realistic, and Time-bound) concept.

The first PDCA cycle aimed to reduce the frequency of unnecessary requests for coagulation and chromogenic factor tests to 50% by the end of 2022. The second PDCA cycle aimed to reduce the frequency of unnecessary requests for coagulation and chromogenic factor tests to 30% by the end of 2023, and to reduce the frequency of requests for coagulation and chromogenic factor tests from non-hematologists to 80%. Ultimately, the overall cost of unnecessary requests for coagulation and chromogenic factor tests was expected to be reduced by 50% per year, thereby achieving the primary goal of controlling unnecessary requests for coagulation tests.

PDCA cycles were implemented by implementing a health informatics system (HIS) that informed physicians of recent laboratory test requests. When necessary, a laboratory representative assessed the test request, contacted the ordering physician, and provided feedback. The HIS was also used as a notification system for repeat tests to prevent duplication. When necessary, a memo was issued outlining the limitations of individual tests. The HIS was configured not to display requests for coagulation and chromogenic factor tests from physicians who were not internists or hematologists. This decision was supported by the data collection and assessment audit team.

After the implementation of the first PDCA cycle, an audit of unjustified requests for coagulation profile and chromogenic factors showed a decrease in their proportion. However, up to 80%, 50% and 50% of factors, including factors 5, 7, and 13, respectively, were still requested incorrectly (p < 0.00001). A more notable progress was recorded in the PDCA cycle 2 from February to October 2023. In 2023, only seven factor 5 tests were performed, of which approximately 28.5% were inappropriate. In addition, the number of inappropriate chromogenic factors decreased to 29% or less. The frequency of ordering most coagulation factor tests by hematologists increased to 100%. The frequency of ordering chromogenic factors by hematologists exceeded 50%.

A comparison of the first and second PDCA cycles showed a marked decrease in the number of requests for inappropriate laboratory tests. As a result, after implementing two PDCA cycles, by the end of 2023, the number of requests for incorrect tests of coagulation factors and chromogenic factors was reduced to less than 30%. The number of tests requiring review increased to 80-100%, and hematologists began to request tests for most parameters. This resulted in a reduction in costs and an overall savings of SR 5,538.97.

In terms of how this research project impacted the laboratory, physicians, and health care system at the clinic, one of the most significant points was the formation of an audit team that included internal medicine residents. This audit process provided a new approach to quality of care and resource management. In addition, this step contributed to continuous medical education, broadened the experience of young colleagues, and instilled in them a positive attitude to develop competent consultants with a high level of knowledge in the field of quality and safety, both in the laboratory and beyond. Finally, this approach prepared young residents to participate in a high-quality project within the Saudi Commission for Health Specialties (SCFHS) Internal Medicine Residency Curriculum.