Marshfield Clinic Lab Tackles Phlebotomy Workflow Redesign

Dramatic reduction in wait times, lower costs, more patient satisfaction

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. ‚ÄúPrior to this improvement¬†project, phlebotomists were located¬†throughout the clinic‚Äôs sprawling main campus and¬†the workflow was both highly inefficient¬†and confusing to patients,‚ÄĚ stated¬†Pam Carter, the clinic‚Äôs Director of System¬†Laboratories. Carter was speaking at the Lab¬†Quality Confab in New Orleans in¬†November.

‚ÄúAfter eliminating waste by redesigning¬†phlebotomy operations, our lab team at the¬†Marshfield Clinic achieved remarkable¬†results,‚ÄĚ stated Eileen Seidel, Manager of¬†Phlebotomy Services. ‚ÄúBefore the redesign,¬†patients sometimes waited to see a phlebotomist¬†for more than 40 minutes.

‚ÄúAfter 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!‚ÄĚ 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.

‚ÄúThe patient experience improved as well¬†because wait time was reduced,‚ÄĚ she commented.¬†‚ÄúAnother 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.‚ÄĚ (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.

‚ÄúWe took a comprehensive approach to¬†solving the problems associated with phlebotomy¬†and the operation of PSCs,‚ÄĚ stated¬†Carter. ‚ÄúSupply 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.

‚ÄúWe did that by questioning the existing¬†design and layout of our PSCs,‚ÄĚ added¬†Carter. ‚ÄúThe laboratory team studied the¬†existing floor plan and applied Lean design¬†principles to the physical layout of each¬†PSC. We engaged Marshfield‚Äôs 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.‚ÄĚ

The project was substantial because¬†Marshfield Clinic is a big healthcare system.¬†‚ÄúWe are the largest private multi specialty¬†medical practice in Wisconsin and will have¬†our 100-year anniversary next year,‚Ä̬†observed Carter. ‚ÄúWe are a¬†physician-led,¬†private, nonprofit organization.

“Marshfield Clinic has 7,000 employees ¬†and 780 physicians,‚ÄĚ she noted. ‚ÄúIt primarily¬†operates outpatient-focused clinics.¬†We don‚Äôt 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

‚ÄúMarshfield‚Äôs 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,‚ÄĚ explained¬†Carter. ‚ÄúAs an outpatient-focused organization,¬†we have 60 locations, including dental¬†clinics and four ambulatory surgery¬†centers. We also do veterinary pathology.

‚ÄúIn addition to providing routine lab¬†services for the clinic at our main campus,¬†we also provide regional and reference lab¬†services as well,‚ÄĚ she said. ‚ÄúThe 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.

‚ÄúWe aim to offer affordable and personalized¬†care, and same day lab-test results for¬†our patients, whenever possible,‚ÄĚ she said.¬†‚ÄúBecause 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.

‚ÄúParticularly over the past 18 months,¬†the focus on cutting costs is what led the¬†clinic to suggest consolidating our multiple¬†phlebotomy stations,‚ÄĚ recalled Carter. ‚ÄúOur¬†lab was asked about what we could do.

‚ÄúThat led us to a series of questions,‚Ä̬†she continued. ‚ÄúCan 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,‚ÄĚ she warned.

‚ÄúAs soon as you walk in the front door¬†of the clinic, our phlebotomy station is¬†right there on the ground floor,‚ÄĚ Carter¬†stated. ‚ÄúThat means everyone‚ÄĒphysicians,¬†administrators, staff, and patients‚ÄĒ¬†will see a problem if there‚Äôs 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.‚ÄĚ

In her role as the clinic‚Äôs Manager of¬†Phlebotomy Services, Siedel knew the¬†details of the project. ‚ÄúAs mentioned earlier,¬†we started with five drawing stations¬†and they were all in one place: right next¬†to the lab,‚ÄĚ she said.

‚ÄúThat‚Äôs what you do: When you need¬†blood collection in one area of your facility,¬†you put in a drawing station,‚ÄĚ she¬†stated. ‚ÄúOver 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.

‚ÄúIn the clinic, we have limited resources¬†for specialized blood collections, which means¬†patients have been directed to¬†numerous locations, which can be confusing,‚Ä̬†observed Seidel. ‚ÄúFor 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

‚ÄúBut scheduling complicates this issue¬†because some patients require a different¬†phlebotomy skill level,‚ÄĚ emphasized¬†Seidel. ‚ÄúIf I staff one drawing station with¬†two phlebotomists‚ÄĒbut neither one can¬†draw a pediatric patient‚ÄĒwhat happens¬†when a pediatric patient arrives?

‚ÄúWe must also accommodate handicapped¬†patients or anyone needing a wheelchair,‚Ä̬†she said. ‚ÄúYet 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.

‚ÄúFor 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‚Äôt think about,‚ÄĚ stated¬†Seidel. ‚ÄúWe also engaged with the Process¬†Improvement Department because we¬†didn‚Äôt want to introduce anything in the¬†new setting that wouldn‚Äôt work. The PI¬†Department helped us analyze and standardize¬†our workflow to make it as efficient¬†as possible.

‚ÄúThen, we looked outside of our industry¬†to the restaurant business to see how¬†to improve the waiting process,‚ÄĚ she continued.¬†‚ÄúMost times laboratories look to¬†for solutions. But many industries¬†face similar challenges and have great¬†process improvement ideas.

‚ÄúWhen we looked at how our patients¬†come into phlebotomy, we did so by¬†tracking each patient and recording the¬†time of day,‚ÄĚ she recalled. ‚ÄúThe process¬†improvement team used software that¬†looked at all of our patient workload data¬†and identified our throughput capabilities.¬†‚ÄúIt 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.

‚ÄúThe metrics told us that we do more¬†than 75% of our workload by noon each¬†day,‚ÄĚ said Seidel. ‚ÄúWhen 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

‚ÄúNow, we had to establish goals to balance¬†supply and demand every hour while also¬†minimizing waiting room times to 15¬†minutes or less,‚ÄĚ said Seidel. ‚ÄúAnother¬†goal was to limit the waiting room size to¬†30 people during peak hours.

‚ÄúThat 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?‚ÄĚ she asked.

‚ÄúTo do that required optimizing staff utilization¬†and load leveling,‚ÄĚ Seidel said.¬†‚ÄúMost phlebotomy departments use the¬†first-come-first-serve method. But if there‚Äôs¬†no set lab appointment time, phlebotomists¬†don‚Äôt know who‚Äôs coming or when.

‚ÄúThus, as a process improvement, we¬†set up lab appointments, which required¬†educating our patients so they would¬†come at their assigned time,‚ÄĚ she¬†explained. ‚ÄúLab appointment times offer¬†several benefits: You can staff appropriately¬†and the patient gets the best patient¬†experience without having to wait.

Paging Patients Next

‚ÄúPlus, our service would be consistent,¬†which is what patients want,‚ÄĚ she added.¬†‚ÄúThey feel less apprehensive. And, you¬†control the environment and how much¬†supply you‚Äôll need each day, all of which¬†standardizes workflow.

‚ÄúTwo other changes helped to improve¬†the waiting process itself,‚ÄĚ noted Seidel.¬†‚ÄúOne 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.

‚ÄúThe other change came from the¬†restaurant industry,‚ÄĚ stated Seidel. ‚ÄúWe¬†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‚Äôs name or¬†use numbers. Part of our streamlined¬†workflow includes cleaning each pager¬†after every patient‚Äôs use.

‚ÄúNow the last change I‚Äôll mention is one¬†that is important to any Lean project and¬†that is visual management,‚ÄĚ offered Seidel.¬†‚ÄúAs each patient checks in, a screen located¬†in the phlebotomists‚Äô work area populates¬†the name and the lab appointment time.

‚ÄúThen we color coordinate to make¬†sure the phlebotomists can maintain an¬†appropriate workflow and identify the¬†next patient,‚ÄĚ she added. ‚ÄúThis 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.

‚ÄúSo, what did all of these changes¬†accomplish?‚ÄĚ concluded Seidel. ‚ÄúAs 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‚Äôre doing¬†more draws. For patients, the wait time¬†was reduced by 80% and we‚Äôve sustained¬†that performance. Labeling errors have¬†been reduced to zero and sustained over¬†seven years since these process improvements¬†were implemented.‚ÄĚ

In conclusion, Sprick said, ‚ÄúThe beauty¬†of this work is that if a lab sustains a Lean¬†culture over time, it increases the employees‚Äô¬†knowledge, skills, experience, and¬†expertise. Self-esteem and engagement in¬†the lab organization goes up, along with rising¬†productivity and a renewed commitment.¬†Isn‚Äôt that what we all want in our¬†work?‚ÄĚ 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.

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Screen Shot 2016-04-20 at 11.22.15 AM

 

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.

‚ÄúIn order to sustain Lean in your lab organization,¬†you have to grow a Lean culture, which¬†requires a Lean management system,‚Ä̬†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. ‚ÄúTo do that your lab must start¬†with organizational alignment around a true¬†culture of continuous improvement. If the lab¬†doesn‚Äôt have a robust Lean management system,¬†what it accomplishes fades over time,¬†before disappearing.

‚ÄúThere are four key elements in a Leanmanagement system,‚ÄĚ she said. ‚ÄúThey are:

1. Leader standard work;

2. Visual controls;

3. Daily accountability; and,

4. Leadership discipline.

‚ÄúAs the management expert W. Edwards¬†Deming said, ‚ÄėYou have to manage the system;¬†the system doesn‚Äôt manage itself.‚Äô Truer words¬†were never spoken,‚ÄĚ emphasized Sprick.

‚ÄúAll these elements need to work¬†together,‚ÄĚ she added. ‚ÄúFor 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.

‚ÄúParticular attention must be paid to handoffs,¬†reviews, and to the continuous improvement¬†projects,‚ÄĚ advised Sprick. ‚ÄúThese are all¬†components of leader standard work‚ÄĒwhich¬†means all managers need to do them throughout¬†the lab organization. Otherwise, a Lean culture¬†will not take root.

‚ÄúNext is the process for daily accountability,‚Ä̬†she continued. ‚ÄúHuddles 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.

‚ÄúVisual controls are essential to Lean and¬†the culture of continuous improvement,‚ÄĚ stated¬†Sprick. ‚ÄúLabs 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.

‚ÄúA key component of visual controls are¬†metrics,‚ÄĚ she concluded. ‚ÄúWhen 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.‚ÄĚ

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