Boston’s Beth Israel Scores Improvement Gains with Lean

Resolved 10-Year Issue of Hemolyzed ED Specimens!

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CEO Summary: Lean methods are helping laboratories resolve aggravating problems that have been unresolvable for as long as 10 years. At Beth Israel Deaconess Medical Center in Boston, improvement teams involving the laboratory and ED staff addressed high rates of hemolyzed specimens. Collaboration among departments and the use of Lean methods produced swift results. The rate of hemolyzed specimens collected in ED has fallen dramatically and now is comparable with rates across the entire hospital. Even the Beth Israel CEO has celebrated this success.

LAB DIRECTORS ARE WELL AWARE of problems that can develop between the laboratory and other departments in a hospital. Often one department has a procedure that makes it difficult for the other to do its job efficiently.

Last fall, Beth Israel Deaconess Medical Center (BIDMC) in Boston set out to solve two such problems. In each case, BIDMC used Lean techniques to identify solutions and produce lasting results. What makes this case study particularly interesting is that both problems are common in hospital settings across the nation—but the solutions were unusual!

Further, these projects attracted the attention of the hospital’s CEO. He bragged about the two successful efforts involving the laboratory in his blog posting.

One problem centered around higherthan normal hemolysis rates for patients in the emergency department who had potassium draws. The other problem involved requiring couriers to follow a needlessly long and confusing process to log patient samples collected in the gastroenterology suite.

The noteworthy elements of this case study are the use of Lean methods to identify solutions and the resulting partnership that developed between the laboratory and the other departments in the hospital. In fact, Gina McCormack, the lab’s operations director, believes partnerships the lab developed with the ED and GI departments are perhaps the most significant result from the entire process.

BIDMC has 621 licensed beds. Its emergency rooms has about 140 patient visits each day.  A teaching hospital of Harvard Medical School, BIDMC is a Level 1 Trauma Center. The lab does 6 million billable tests annually.

McCormack described the hemolysis issue for patients in the ED. “This problem has existed for 10 or more years and has been the subject of many discussions during that time,” she said. “In the lab, we were confident we understood the source of the problem. But whenever we tried to tell ED staff how to solve these problems, we got nowhere. We would say, ‘This is what the problem is and you create more work because you try to avoid peripheral needle sticks. Yet, in fact, you are sticking people unnecessarily.’ This is because ED nurses commonly used IVs when drawing potassium samples from patients.”

One measure of quality in any ED is the hemolysis rate, meaning the number of defective specimens compared with the total number of specimens drawn. Hemolysis can skew a patient’s test results, thus requiring a redraw and retest.

Hospital CEO’s Blog

BIDMC’s President and CEO, Paul Levy, in his blog, “Running a Hospital,” wrote last fall that, “the hemolysis rate for lab specimens collected in the ED was found to be 22.4%, approximately five times their counterparts on the inpatient units (3.9%). This rate had several deleterious effects: patients’ hemolyzed specimens often had to be recollected and retested, therefore these patients had to wait on average 56 minutes longer for lab results, and frustration levels in both the ED and the laboratory were high.”

As Levy explained, hemolysis can result from improper specimen collection. Decreasing this rate would improve ED throughput, cut patient length of stay, and improve patient satisfaction. But also, cutting the hemolysis rate would reduce the need for recollections, along with savings in both time and materials.

“Rework is frustrating for everyone, particularly for patients,” McCormack commented. “When the specimens have to be recollected and retested, those patients must wait, on average, 56 minutes longer for lab results. The protocol in our laboratory is that if we get a critical value for a certain test— whether it is hemolyzed or not—we will repeat the test, document it, and flag it for discussion. We call it to the attention of the ED, and follow the critical value policy of writing it down and reading it back and then documenting these steps in our computer system, all of which involves increased steps and work.

“We knew everyone was well intentioned, and that everyone wanted to deliver the best care, but the ED wanted to do specimen collection a little differently,” she said. “To discuss the problem and work together on a solution, we assembled a working team made up of staff from the lab, the ED, and any other department that was affected. In a kaizen event, over two or three days, we examined every step in the procedure of drawing samples in the ED.

“We learned, for example, that the ED staff was trying to be as efficient as possible,” explained McCormack. “For their part, they learned that they didn’t know the best procedure for collecting these samples. Next, our laboratory staff observed the processes for specimen collection used in the ED. That helped our lab staff learn how and why the ED was collecting specimens in this manner. For example, ED nurses used IVs to do the patient draws, which is a collection method that can increase the hemolysis rate.” “

BIDMC’s IV and phlebotomy experts do not recommend IV draws. Neither does the IV product manufacturer, in part because of the risk of hemolysis,” she added. “Yet, the ED staff worried that they would be sticking each patient twice (once to set-up an IV and a second time to draw blood through venipuncture). Yet, almost 30% of the time, the IV method resulted in the need to stick patients twice because of hemolysis.

IV Draws And Hemolysis

“When we explained that IV draws have higher rates of hemolysis, the ED nurses said, ‘That can’t be the reason for the high rate of hemolysis experienced here in the ED. You would be having this problem elsewhere because a lot of people in the hospital draw through IVs.’

“It turned out that one other department takes samples with IV draws, but they draw for creatinine and kidney function tests, which aren’t impacted by hemolysis,” McCormack continued. “Because they weren’t drawing the potassium test, this department was not getting requests for redraws, nor was this collection method creating extra work in the laboratory.

“We did a further investigation,” she noted. “We studied all the sample draws for that department over a two-day period. We determined that the hemolysis rate was 30%! But, because this had no affect on the tests being ordered, and no adverse affect on patient care, it was not a problem.

Pivotal “Ah Ha” Moment

“That was the pivotal, ‘Ah ha,’ moment for our lab/ED improvement team,” she added. “Both sides recognized the root cause of the problem. The nurses recognized that, although the practice of collecting blood specimens via the IV was motivated by doing the best for patient care, it was a practice that produced a high rate of hemolyzed specimens. In turn, that meant a redraw for about 30% of their patients— generating the second needle stick that they had been attempting to avoid!”

After two days of analyzing the problem and doing root cause analysis, McCormack says that a very thorough exchange of ideas took place. Agreement on new procedures was accomplished with much harmony and collaboration. “To stop collecting blood specimens at IV insertion, BIDMC assigned ED technicians to draw all blood,” stated McCormack.”“Under the revised ED protocol, ED techs can draw only via venipuncture. At the same time, BIDMC’s phlebotomy team retrained the ED techs according to the pathology department’s venipuncture standards.”

Once the new process was implemented, McCormack reviewed the results. “Since we did this work flow redesign, the hemolysis rate in the ED is consistently about 6% or 8%,” she said. “This is the normal rate for every department in the hospital because, even when a specimen is drawn the right way, it can hemolyze. It’s just a fact of life.

“What is significant is that the hemolysis rate in the ED now matches the hemolysis rate for the rest of the hospital,” explained McCormack. “There is now a benchmark rate for the ED. Even better, our laboratory has a much stronger and productive relationship with ED staff. By itself, that is a powerful result. Another notable outcome is that the process was mutual and collaborative between the laboratory and the ED.

“ Lean methods for process redesign also played a key role in resolving another ongoing problem at Beth Israel Deaconess Medical Center. The second problem involved transport of patient specimens from the gastroenterology suite to the laboratory. Again, McCormack was on the Lean improvement team that reviewed the previous process and recommended a new one.

“Our approach in this problem-solving project was different than the step-by-step analysis of work flow conducted by the entire team in the kaizen project to reduce hemolysis rates from specimens collected in the ED,” noted McCormack. “For the GI project, the Lean team designated specific individuals to do what’s called ‘value capture.’ We actually partnered with a company called Value Capture, LLC, in Pittsburgh, Pennsylvania. They documented all steps in the process being studied. Each step was evaluated, then a report was made to the entire Lean team.

Transport From GI Suite

“The problem occurred when transport picked up specimens at the GI suite to bring them to the laboratory” McCormack explained. “In the GI suite, GI staff would put the specimens in a bag. Next, staff would write on a log sheet what specimens should be in the bag. The problem hinged around a major complication.

“Early each day, GI staff prepared the log sheet, with each patient listed by time of appointment,” recalled McCormack. “However, during the day, patients were not served in alphabetical order. Thus, when transport arrived several times over the day to pick up specimens, it was difficult for transport to acknowledge which specimens were in the bag and which specimens belonged to a specific patient. Our first improvement was to put the log sheet in alphabetical order.

“When Beth Israel Deaconess operated two GI suites, this process was onerous but doable,” McCormack added. “However, that changed when the two GI suites were combined into one. A single transport person was required to sort out all these matters. For them, it became a regular nightmare, experienced several times daily and was a significant reason for all sorts of problems further downstream as GI specimens reached the laboratory.

‘The improvement team identified a number of issues,’” stated McCormack. “One, steps for transport to sign out each individual specimen were unnecessarily time consuming. Two, paperwork to accompany each specimen was not always completed by GI staff in a timely or uniform manner. Three, there was no reconciliation when GI specimens arrived in pathology. Four, there was no feedback about missing specimens. Five, not all required steps were standardized.

The Value Capture Process

“This Lean team was made up of individuals from GI, nursing, administration, pathology, transport, and Value Capture,” she related. “We had the Value Capture people analyze the steps. Our team then devised a series of procedures that eliminated use of the log sheet with the alphabetical list of names. Instead, GI staff listed patients on the log sheet as each patient’s samples came out of the suite.

“Another change was to put each patient’s sample in a clear plastic bag that showed the number of specimens from each patient,” she continued. “The trans- porter would collect the samples at the GI suite, note the number of samples for each patient, along with the name of the patient. As these specimens were delivered to pathology, staff there would receive each sample and note the number of tubes from each patient. These were simple steps, but they markedly improved the accuracy and productivity of this work flow.

“As part of the work flow redesign, the Lean team had the specimen tracking book moved to a more convenient central location in the GI suite, reducing delays,” McCormack said. “One nurse in GI was designated to identify all specimens. Also, the transporter no longer needed to sign out each individual specimen by patient name.”

Cutting Transport Time

Improvements were swift and substantial. “The result was a reduction of 57% in the amount of time between when a GI specimen was ready for transport and when transport arrived to pick the specimen up,” commented McCormack. “There was an overall reduction of 61% in the time it took to transport GI specimens to pathology. The new work flow freed up hours of transport time, improving productivity and reducing the cost of transport. There was improved patient safety and quality was maintained.”

These Lean process improvement successes at Beth Israel Deaconess Medical Center demonstrate how many of the nation’s most respected hospitals have embraced Lean and similar quality management methods. Equally notable is how use of Lean in cross-disciplinary improvement teams created the communication to resolve the ED hemolysis issue—an issue that had eluded resolution for 10 years!

Hospital President Lauds Lean Project of Lab & ED

IN HIS BLOG “RUNNING A HOSPITAL,Paul Levy, President and CEO of Beth Israel Deaconess Medical Center, recognized the Lean improvement project to address hemolysis in emergency department specimens.

The laboratory and the emergency department (ED) came together. Levy wrote that “each area owned this problem and for various reasons wanted to find a solution. The lab would have fewer critical values to repeat, call, and document. The ED would have fewer patients to re-stick, faster results, and happier patients.” Levy noted that the following was learned and communicated to the respective Lab staff and ED staff:

  • Long tourniquet time (>1 minute) increases hemolysis.
  • IV product manufacturer does not support blood draws from IV equipment.
  • Medical center IV and phlebotomy experts do not teach or recommend IV draws.
  • Most ED staff worried about sticking the patient twice (once to set-up an IV and again to draw blood through venipuncture)—creating a negative experience for the patient. However, almost 30% of the time they did stick people twice due to hemolysis which created a 56-minute delay.

 

Mayo Clinic Uses RFID tags To Track GI Samples to Lab

OTHER HOSPITALS HAVE THE PROBLEM OF FINDING THE BEST WAY TO identify and track samples from the gastroenterology suite to the pathology department. In January 2007, Mayo Clinic of Rochester, Minnesota, announced that it would begin using radio frequency identification (RFID) tags to track biopsy specimens from its 41 operating rooms to pathology. As many as 20,000 endoscopy and colon procedures are done annually in these operating rooms. (See TDR, January 29, 2007.)

THE DARK REPORT noted, at the time, that Mayo’s use of RFID to track lab specimens was an important technology breakthrough for the lab industry. RFID has the potential to improve laboratory operations and work processes in many ways.

Mayo’s decision to deploy RFID in this manner followed a five-month pilot program in 2006 that used RFID tags and scanners manufactured by 3M Corporation. The pilot program involved five GI operating rooms and one laboratory. Mayo tracked 1,800 tissue samples from the surgery suites to the lab. Benefits identified during this pilot program were increased productivity, fewer errors, and improved patient safety.

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