CEO SUMMARY: Physician residents at the UCSF School of Medicine set a target of reducing unnecessary blood draws. By eliminating needless needle sticks, the residents are focusing on patient experience while also encouraging physicians to pay more attention to the need to decrease unnecessary clinical lab testing. The goal is a 5% reduction in phlebotomy procedures for the academic year 2014 to 2015, compared with the previous academic year. Early results show a decrease in phlebotomy procedures.
TREATING PHYSICIANS ARE SEIZING THE INITIATIVE to eliminate unnecessary clinical laboratory testing and the number of phlebotomy procedures performed on hospital inpatients.
This is the goal of a program developed by internal medicine residents at the University of California San Francisco School of Medicine (UCSF), a large tertiary-care academic medical center. During the 2014 to 2015 academic year, these physicians expect to reduce the number of phlebotomy draws per patient per day by at least 5%, as compared with draws done in 2013 to 2014.
“The program is in place within UCSF’s internal medicine teaching service, which has a mean daily census of 88 patients,” stated Daniel J. Wheeler, M.D., a Resident Physician in the Department of Medicine. “This effort to reduce inpatient testing is known as the ‘Think Twice, Stick Once’ campaign.
“From the beginning, our group sought a project that would achieve the Institute for Healthcare Improvement’s Triple Aim of improving patient care, patient experience, and costs of care,” explained Wheeler. “We thought phlebotomy reduction was the ideal project to meet those goals.
“Specifically, we targeted the reduction of unnecessary blood draws,” he commented. “Overuse of testing is not a problem limited to phlebotomy; however, blood draws are a high frequency event in the hospital, which made this a good target for intervention.
Targeting Blood Draws
“It is our hope that changing the culture of phlebotomy will in turn affect how providers at UCSF think about other medical interventions, such as imaging studies and procedures,” added Wheeler.
“Plus, by measuring phlebotomy frequency rather than the total number of tests, we are emphasizing the importance of patient experience while also providing high-value care and avoiding unnecessary patient harm,” he said. “By eliminating needless needle sticks, we are improving the patient experience. Further, we expect the data on improved patient outcomes will provide clinicians with a compelling reason to decrease unnecessary testing.
“Because the project began last summer, it’s a bit early to say whether our intervention has moved the needle on patient satisfaction scores,” stated Wheeler. “We also recognize that it will be difficult to prove a causative effect in retrospect.
Boosting Satisfaction Scores
“Anecdotal and qualitative evidence shows that frequent phlebotomy sticks are uncomfortable for patients,” he said. “Thus, our efforts to quantify the effect of phlebotomy reduction on patient satisfaction are ongoing.
“We started the project on July 1,” noted Wheeler. “It included the educational campaign, data collection, and performance feedback. From July to September we did not see much change in the number of blood draws per patient per day.
“However, we saw a clear decrease in blood draws from October onward,” he continued. “That’s when real downward changes in our phlebotomy numbers began to show up. This program is truly driven by residents and has led to changes in how residents order blood tests.”(See sidebar on page 9.)
“Undoubtedly, there are multiple factors for this timing, but a big one is that the academic year begins in the summer,” said Wheeler. “That’s when members of the residency house staff are growing into new roles. We believe that is why there was some lag time before practice patterns of lab test ordering became visible.”
Residents Created Program
Pathologists should take note about an interesting aspect of the “Think Twice, Stick Once” campaign. It was originated by internal medicine residents and led by them. In this sense, it shows how the thinking of clinicians is changing now that they are being asked to identify and implement programs that improve patient safety and contribute to better patient outcomes.
“Because we focused on the ordering of lab tests, we did not discuss our initial intervention with the Department of Pathology or the laboratory,” recalled Wheeler. “In fact, our communication with the lab has been minimal-in part because the project has operated almost entirely at the direct clinical/provider level. This is due to the fact that our focus was on the act of ordering lab tests.
“Our primary role was to educate those who place orders for tests, namely, the internal medicine house staff,” Wheeler said. “Also, we did not hear any concern from the lab about reduced testing. In fact, the project received positive feedback from lab leadership.
Unnecessary Blood Tests
“While we didn’t hear concerns about reduced testing, we were, nonetheless, aware that running a project that aims to reduce unnecessary blood tests could unintentionally lead to a reduction in lab tests that actually affect medical management,” he added. “Lab tests are essential to patient care, and we are sensitive to the concern that attempts to reduce even unnecessary phlebotomy could have a negative effect.
“However, it is also possible that a reduction in unnecessary phlebotomy could have a positive impact on patient outcomes. As we move forward, it will be important to look at balancing measures that link phlebotomy usage with clinical outcomes,” he added.
“To reinforce that important point, our educational campaign emphasized that the focus is to help physicians reduce unnecessary clinical laboratory tests,” commented Wheeler. “We explained that the primary goal was to reduce the number of blood draws as opposed to the number of lab tests ordered.
“By calling attention to the number of blood draws, the emphasis is thus placed on the patient experience,” he noted. “Of course, our program also asks residents to consider not only if a test should be ordered, but also when.
“For example, non-urgent lab tests can sometimes wait until the next morning rather than being drawn immediately,” he observed. “This avoids causing an extra, unnecessary, uncomfortable poke. ICU patients were excluded from our data collection because they often need more frequent monitoring and testing.”
One visible reward for improving the patient experience is that the program is expanding within UCSF. “The Division of Hospital Medicine started tracking phlebotomy usage just when we started our project and now follows phlebotomy usage as a performance metric for its non-resident services,” he said. “The division’s decision to track this data was not a direct response to our early successes, but it is evidence of a growing acknowledgement of the importance of the initiative.
At USCF Medical Center, Residents Use Education to Reduce Number of Phlebotomy Procedures
RESIDENTS IN THE INTERNAL MEDICINE SERVICE at the University of California San Francisco School of Medicine implemented an interprofessional educational campaign to reduce unnecessary clinical laboratory testing focused on phlebotomy.
The residents produced timely feedback of team-specific phlebotomy data and used financial incentives to change practices related to inpatient laboratory testing, according to an abstract the Society of Hospital Medicine published for its annual meeting March 29 to April 1 in Baltimore, Maryland. In the medical center’s “QI Incentive Program,” each resident physician was eligible for an annual $400 reward for meeting a specific performance goal.
To create awareness and change the behavior of clinicians, the residents publicized the project to house staff, nurses, and faculty by using the slogan “Think Twice. Stick Once.” The educational campaign utilized the following activities:
- An introduction of strategies for phlebotomy reduction during monthly house staff orientation sessions;
- Posters and pens featuring the slogan “Think Twice. Stick Once;”
- A “Facilitator’s Guide” for all attending physicians that includes suggestions for discussing appropriate use of lab tests with trainees;
- Discussions at monthly didactic sessions regarding best practices for appropriate lab test ordering.
To track progress, each of eight internal medicine teams reports team-specific phlebotomy data twice monthly. All members of the teams can view the data and thus can compare one team against others.
During the academic year prior to project implementation (2013 to 2014), the average phlebotomy usage across all medicine teams was 2.09 draws per patient per day.
In the current academic year (2014 to 2015), after the first three months of the project, there was no change in average phlebotomy use. However, during the fourth and fifth months, the average dropped to 1.93 draws per patient per day, suggesting possible improvement. The “Think Twice, Stick Once” program has the goal of reducing the overall number of phlebotomy procedures per patient by 5%, when compared with the prior year.
Phlebotomy Usage Metric
“All of these efforts show that the project has been well received within the residency program and in our Division of Hospital Medicine,” noted Wheeler.
Recognizing that it is important to share the positive outcomes for this initiative, Wheeler and his colleagues have taken the opportunity to present the program in other settings. “Multiple groups have heard our presentation,” he said. “For example, we submitted the project to the UCSF Medical Center’s Resident and Fellow QI Incentive Program, which works with resident groups to promote quality improvement.
“Our project was accepted into the program, which provides all participating house staff with a financial award of approximately $400 per person for meeting a stated performance goal,” stated Wheeler. “Within our department, the goal is to reduce the number of phlebotomy draws per patient per day by 5% compared with draws done in the prior academic year.
“We also discussed the project with the Division of Hospital Medicine, and DHM has been very supportive of the project,” he continued. “DHM currently reports the same phlebotomy data to its hospitalist service. Also, along the way we received wonderful mentorship from within the Division of Hospital Medicine.”
What’s Next at UCSF?
What’s next for the UCSF Internal Medicine teaching service? “Now that we have early success in reducing the number of phlebotomy procedures, we are considering how to move the project forward,” noted Wheeler. “One idea is to collaborate with the hospital lab staff to identify specific tests that are typically needed only once during a patient’s hospitalization.
“Our hope is to use the electronic medical record to call attention to such lab tests and remind providers that they need not be ordered more than once during a patient’s hospital stay,” he explained. “We are considering other cultural changes to lab test ordering, such as the utility of ordering lab panels versus single tests. These are ideas that we hope to discuss with the lab staff in the future.”
Opportunities for Lab to Help Improve Care
ONE EXPERT IN HEALTH POLICY URGES pathologists and laboratory professionals to engage clinicians more actively to improve utilization of clinical lab tests.
“The ‘Think Twice, Stick Once’ initiative here at UCSF shows the potential that exists for clinical laboratory directors to have an important role in helping to develop such programs in hospitals,” stated R. Adams Dudley, M.D., Professor of Medicine and Health Policy and Director of the UCSF Center for Healthcare Value.
“Healthcare’s emphasis on improved patient outcomes and a better patient experience in hospitals makes the time ripe for lab directors to take the initiative with these types of programs,” continued Dudley. “Lab directors have big advantages over other clinicians in terms of access to data, and they knowor at least could calculate-how many tests are done per patient per day. Other clinicians have only a vague sense about this issue and don’t have the data to check.
“Lab directors also know which tests are more expensive and which ones have higher false positive rates,” he said. “False positives are particularly problematic in terms of waste, because they lead to unnecessary additional testing or, even worse, unnecessary treatment. Pathologists also understand which lab test numbers change slowly over time for a hospital inpatient, meaning that there is no reason for physicians to check them frequently.
“For all these reasons, experts in laboratory medicine and pathology can use their knowledge to bring together different services and help them figure out how to implement programs like ‘Think Twice, Stick Once,'” observed Dudley. “Clinical laboratory directors are uniquely positioned to stimulate interdisciplinary conversations about how to make care better in terms of cost and patient experience through improved utilization of lab tests.”
Contact Daniel Wheeler, M.D., at Daniel.Wheeler@ucsf.edu; Adams Dudley, M.D., at Adams.Dudley@ucsf.edu or 415-476-8617.