CEO SUMMARY: Before a redesign of phlebotomy workflow at Marshfield Clinic, patients might wait as long as an hour, particularly before noon when phlebotomists would see 75% of each day’s patients. After the redesign, the number of draw sites was reduced from five to two while handling an increase in daily patient volume from 700 to 855. Patient wait times fell to a range of two to 10 minutes. Prior to the Lean project, the department corrected four to five clerical errors each week before transportation and testing. After the Lean project, clerical errors dropped to zero and the clinic has sustained that level over time.
EVERY CLINICAL LABORATORY faces the identical challenge with its patient service centers and phlebotomy services: how to keep wait times at a patient-friendly level while dealing with the morning surge of patients that drops off during the day.
What can further aggravate patients is a disjointed workflow at the PSC and phlebotomists who struggle to meet the expectations of patients because the venipuncture does not go well or causes unnecessary discomfort and even pain.
At Marshfield Clinic in Marshfield, Wisconsin, a process improvement team in the clinical laboratory was challenged with tackling all of these problems. Armed with tools of Lean, Six Sigma, and process improvement, the team set out to improve the patient experience at the outpatient PSCs, while also reducing wait times, cutting unnecessary costs, and balancing the phlebotomy workload throughout the day.
The need to tackle phlebotomy workflow was obvious. “Prior to this improvement project, phlebotomists were located throughout the clinic’s sprawling main campus and the workflow was both highly inefficient and confusing to patients,” stated Pam Carter, the clinic’s Director of System Laboratories. Carter was speaking at the Lab Quality Confab in New Orleans in November.
“After eliminating waste by redesigning phlebotomy operations, our lab team at the Marshfield Clinic achieved remarkable results,” stated Eileen Seidel, Manager of Phlebotomy Services. “Before the redesign, patients sometimes waited to see a phlebotomist for more than 40 minutes.
“After our Lean redesign project, we were able to reduce the number of draw sites from five to two and yet increased collections from 700 to 855 per day!” noted Seidel.
“Through the redesign and process improvement project we decreased the needed staf fing resources to operate the PSCs. This was an important outcome because phlebotomy resources are limited and difficult to find at times.
“The patient experience improved as well because wait time was reduced,” she commented. “Another benefit of this Lean project was a reduction in the volume of clerical errors that needed to be corrected prior to specimens being sent to the main laboratory for testing.” (See chart below.)
These are impressive results and contributed to a measurable increase in patient satisfaction with phlebotomy and the lab’s specimen collection process. To achieve these results, the laboratory team engaged professional expertise outside of the Phlebotomy Department to reinforce the culture of Lean and process improvement, to accelerate implementation of improvements to phlebotomy workflow, and to improve PSC design and layout. Leslie Sprick, CEO of Sprick Group LLC in Mooresville, North Carolina, contributed to the success of this project.
“We took a comprehensive approach to solving the problems associated with phlebotomy and the operation of PSCs,” stated Carter. “Supply management was fine-tuned and workflow was standardized. But, because we wanted to achieve a paradigm shift in the performance of our patient service centers, we dove deeper.
“We did that by questioning the existing design and layout of our PSCs,” added Carter. “The laboratory team studied the existing floor plan and applied Lean design principles to the physical layout of each PSC. We engaged Marshfield’s Performance Improvement Department to validate and test the redesign plan. We then sought ideas from outside of the lab industry and innovated by applying current tools differently.”
The project was substantial because Marshfield Clinic is a big healthcare system. “We are the largest private multi specialty medical practice in Wisconsin and will have our 100-year anniversary next year,” observed Carter. “We are a physician-led, private, nonprofit organization.
“Marshfield Clinic has 7,000 employees and 780 physicians,” she noted. “It primarily operates outpatient-focused clinics. We don’t do a lot of hospital work. In our laboratory, we do some hospital inpatient testing for our large multi specialty hospital on the main campus, but currently there are not many hospitals in our system.
Serving a Large Rural Area
“Marshfield’s service area includes the entire northern half of Wisconsin and there are some patients from the Upper Peninsula of Michigan who travel to our clinic for specialty services,” explained Carter. “As an outpatient-focused organization, we have 60 locations, including dental clinics and four ambulatory surgery centers. We also do veterinary pathology.
“In addition to providing routine lab services for the clinic at our main campus, we also provide regional and reference lab services as well,” she said. “The reference lab allows us to do about 98% of all the tests that our providers order. Last year, the lab did approximately 3.8 million tests with about 425 full-time equivalent employees spread across those 60 locations. We have 18 physician FTEs and 10 veterinary pathologists.
“We aim to offer affordable and personalized care, and same day lab-test results for our patients, whenever possible,” she said. “Because we serve such a large geographic area, our couriers travel about 10,000 miles a day, which shows the rural nature of our business. All of these factors make it a challenge to manage our costs.
“Particularly over the past 18 months, the focus on cutting costs is what led the clinic to suggest consolidating our multiple phlebotomy stations,” recalled Carter. “Our lab was asked about what we could do.
“That led us to a series of questions,” she continued. “Can we improve throughput? Can we streamline the draw process? Should we revise the layout? But all of these issues paled in comparison to the biggest concern I had about doing any work on phlebotomy,” she warned.
“As soon as you walk in the front door of the clinic, our phlebotomy station is right there on the ground floor,” Carter stated. “That means everyone—physicians, administrators, staff, and patients— will see a problem if there’s any backup whatsoever. Being highly visible made the project much more of a challenge because it meant we had to succeed in improving efficiency enough to boost throughput.”
In her role as the clinic’s Manager of Phlebotomy Services, Siedel knew the details of the project. “As mentioned earlier, we started with five drawing stations and they were all in one place: right next to the lab,” she said.
“That’s what you do: When you need blood collection in one area of your facility, you put in a drawing station,” she stated. “Over 20 years, one drawing station grew to be five drawing stations and we needed staff for those five stations and the number of staff varies by station.
“In the clinic, we have limited resources for specialized blood collections, which means patients have been directed to numerous locations, which can be confusing,” observed Seidel. “For example, previously, a patient might see a provider on the fourth floor and be sent to the second floor for a phlebotomy draw. But the next month, they might be sent to the third floor. So, putting all phlebotomy in one place was a priority.
Complicated Scheduling
“But scheduling complicates this issue because some patients require a different phlebotomy skill level,” emphasized Seidel. “If I staff one drawing station with two phlebotomists—but neither one can draw a pediatric patient—what happens when a pediatric patient arrives?
“We must also accommodate handicapped patients or anyone needing a wheelchair,” she said. “Yet in our older facility, the doors are too narrow to accommodate most wheelchairs today because they are wider than they once were. Plus, special draws can show up at any time. So, our patient servicecenters had to be ready for anything.
“For these reasons, we engaged the lab staff to help with assessing the floor plan and physical layout of the PSCs. This step is one most labs don’t think about,” stated Seidel. “We also engaged with the Process Improvement Department because we didn’t want to introduce anything in the new setting that wouldn’t work. The PI Department helped us analyze and standardize our workflow to make it as efficient as possible.
“Then, we looked outside of our industry to the restaurant business to see how to improve the waiting process,” she continued. “Most times laboratories look to for solutions. But many industries face similar challenges and have great process improvement ideas.
“When we looked at how our patients come into phlebotomy, we did so by tracking each patient and recording the time of day,” she recalled. “The process improvement team used software that looked at all of our patient workload data and identified our throughput capabilities. “It matched that data with the time each patient checked in and the length of time each patient spent in phlebotomy. That told us how fast patients moved through the PSC and what staffing level we needed to maintain the level of service we wanted.
“The metrics told us that we do more than 75% of our workload by noon each day,” said Seidel. “When we draw about 800 patients a day, that means 600 of them arrive in the first five hours. Those are key statistics because we needed to have enough space for each patient and we needed enough phlebotomists to do the work.
“One interesting fact about the design of waiting rooms in healthcare is that, many times you count only patients. But, in reality, you need enough chairs for almost every patient’s mom, dad, child, or friend. The data we gathered showed that our PSCs needed room and chairs for one more person for every patient.
Balancing Supply, Demand
“Now, we had to establish goals to balance supply and demand every hour while also minimizing waiting room times to 15 minutes or less,” said Seidel. “Another goal was to limit the waiting room size to 30 people during peak hours.
“That was a challenging goal we set for ourselves: How do we draw 800 patients before noon and make sure that no more than 30 people are in the waiting room at one time and no patient waits more than 15 minutes?” she asked.
“To do that required optimizing staff utilization and load leveling,” Seidel said. “Most phlebotomy departments use the first-come-first-serve method. But if there’s no set lab appointment time, phlebotomists don’t know who’s coming or when.
“Thus, as a process improvement, we set up lab appointments, which required educating our patients so they would come at their assigned time,” she explained. “Lab appointment times offer several benefits: You can staff appropriately and the patient gets the best patient experience without having to wait.
Paging Patients Next
“Plus, our service would be consistent, which is what patients want,” she added. “They feel less apprehensive. And, you control the environment and how much supply you’ll need each day, all of which standardizes workflow.
“Two other changes helped to improve the waiting process itself,” noted Seidel. “One was to establish a separate waiting room for children. Often, adults get agitated when children are crawling around, crying, or being disruptive. Thus, having that space for children allowed the main waiting room to be as calm and soothing as possible.
“The other change came from the restaurant industry,” stated Seidel. “We now give each patient a pager so that when the phlebotomist is ready, he or she pages that patient. That also eliminates the need to call out the patient’s name or use numbers. Part of our streamlined workflow includes cleaning each pager after every patient’s use.
“Now the last change I’ll mention is one that is important to any Lean project and that is visual management,” offered Seidel. “As each patient checks in, a screen located in the phlebotomists’ work area populates the name and the lab appointment time.
“Then we color coordinate to make sure the phlebotomists can maintain an appropriate workflow and identify the next patient,” she added. “This board will change the color for a specific patient every five minutes from green to yellow to red. Once a patient has waited 20 minutes, it goes to red. That means we need to take some action This visual is updated every three minutes or when a patient checks into the lab drawing station.
“So, what did all of these changes accomplish?” concluded Seidel. “As mentioned earlier, we now have 60% fewer drawing stations. That freed up valuable space in those facilities. We also have fewer phlebotomists and yet we’re doing more draws. For patients, the wait time was reduced by 80% and we’ve sustained that performance. Labeling errors have been reduced to zero and sustained over seven years since these process improvements were implemented.”
In conclusion, Sprick said, “The beauty of this work is that if a lab sustains a Lean culture over time, it increases the employees’ knowledge, skills, experience, and expertise. Self-esteem and engagement in the lab organization goes up, along with rising productivity and a renewed commitment. Isn’t that what we all want in our work?” she asked.
Contact Eileen Seidel at seidel.eileen@marshfieldclinic.org; Pam Carter at carter.pam@marshfieldclinic.org; Leslie Sprick at leslie.sprick@sprickgroup.com.
Serving More and Happier Patients in Fewer PSCs and in Less Time with Greater Satisfaction
THESE TWO TABLES DEMONSTRATE the impressive improvements that resulted from a Lean process improvement project by the laboratory team to redesign phlebotomy workflow at the Marshfield Clinic.
Table A shows how patient wait times were improved to meet patient expectations at any time of the day.
Table B provides the key metrics that the lab’s Lean team tracked to show the effectiveness of its improvement project.
Sustaining Lean Improvements in the Lab Requires a Cultural Change in Staff Thinking
ONE CHALLENGING aspect of introducing Lean methods and Lean thinking in a clinical laboratory is sustaining the improvements over time.
“In order to sustain Lean in your lab organization, you have to grow a Lean culture, which requires a Lean management system,” observed Leslie Sprick, Owner and CEO of Sprick Group LLC in Morresville, N.C. Sprick consulted with the Marshfield Clinic on a Lean project last year. “To do that your lab must start with organizational alignment around a true culture of continuous improvement. If the lab doesn’t have a robust Lean management system, what it accomplishes fades over time, before disappearing.
“There are four key elements in a Leanmanagement system,” she said. “They are:
1. Leader standard work;
2. Visual controls;
3. Daily accountability; and,
4. Leadership discipline.
“As the management expert W. Edwards Deming said, ‘You have to manage the system; the system doesn’t manage itself.’ Truer words were never spoken,” emphasized Sprick.
“All these elements need to work together,” she added. “For example, with leader standard work, lab managers need to have regular gemba walks and do these daily whenever possible because it creates daily accountability. It is also essential to conduct frequent meetings to discuss problems, identify solutions, and to recognize successes. These can be standup meetings, or informal huddles. It does not matter what they are called.
“Particular attention must be paid to handoffs, reviews, and to the continuous improvement projects,” advised Sprick. “These are all components of leader standard work—which means all managers need to do them throughout the lab organization. Otherwise, a Lean culture will not take root.
“Next is the process for daily accountability,” she continued. “Huddles come to mind or any meeting in which lab managers review the cycle of plan-do-check-act (PDCA). This cycle must be repeated over and over again. Also needed is the discipline to review it daily or weekly.
“Visual controls are essential to Lean and the culture of continuous improvement,” stated Sprick. “Labs can have huddle boards in every department, along with huddle process standards among departments. It is essential that all huddle boards have a consistent format and look. The process of conducting huddle meetings must be the same in all lab departments.
“A key component of visual controls are metrics,” she concluded. “When a lab team hits its goals, show it in green. If not, show it in red. Then post it where everyone can see it. That provides immediate feedback and staff at the bench level can see it each day. One good technique is to conduct kaizen events, which is an effective way to engage staff and produce fast improvements throughout the lab.”
