Clinical laboratory diagnostic stewardship as boundary infrastructure: a multi-stakeholder qualitative study of digital public health governance in two Chinese regional referral hospitals.

BACKGROUND

Digital public health within population-serving hospitals depends on governance that connects diagnostic information to accountable action. This study examined how digital systems, interpretive expertise, professional authority, and communication practices jointly organized clinical laboratory diagnostic stewardship.

METHODS

An interpretive, multi-stakeholder, contrasting-case qualitative study was conducted from May 2025 to January 2026 in two purposefully selected tertiary Grade-A hospitals in Shaoyang, China. A critical realist position combined attention to organizational conditions with a fallibilist, interpretive epistemology. Forty-six stakeholders completed semi-structured interviews; 36 contextual workflow documents supported process mapping. Chinese transcripts were analyzed abductively using reflexive thematic analysis, role- and site-comparison matrices, and discrepant-case analysis. SRQR guided overall reporting and COREQ supplemented interview-specific disclosure. Anatomical pathology was excluded.

RESULTS

Four interdependent functions were developed: epistemic qualification; jurisdictional authorization; accountable handoff; and recursive institutionalization and learning. Participants associated Hospital A's accredited, more formalized configuration with traceability and reproducibility, but also with generic comments, alert burden, and procedural closure. Hospital B's more relationship-dependent configuration was associated with contextual responsiveness and access to known experts, but also with person-dependence, weaker after-hours coverage, and limited auditability. Accounts of nurse-mediated relay, ordering friction, contextual interpretation, and rule ownership supported a cross-cutting explanation of how formal arrangements and accessible expertise complemented one another. Proposed evaluation indicators were not measured outcomes.

CONCLUSION

Diagnostic stewardship is interpreted as boundary infrastructure connecting evidentiary limits, advisory authority, action ownership, service coverage, and rule learning. The study provides context-bounded explanatory propositions and a separate prospective evaluation agenda, not estimates of effectiveness or hospital performance.