WellSpan’s Lab Designs the “Ideal” Phlebotomy

Identical layout and work flow used in all 13 of their PSCs

CEO SUMMARY: Lengthy wait times for patients at phlebotomy sites is a common problem for labs across the country. But the laboratory at WellSpan Health System in York, Pennsylvania decided to apply Lean methods to change this situation. Their Lean projects at two pilot patient service centers (PSC) produced a reduction in average waiting times by 80% and 75%, respectively. More impressively, the Lean time produced these outcomes at minimal cost and no increase in staff.

IN YORK, PENNSYLVANIA, THERE IS AN UNUSUAL STORY about how an intrepid band of laboratory administrators and managers at WellSpan Health and York Hospital set out to create the “ideal” patient service center (PSC).

Their goal was to create a single optimal facility layout and a standard workflow that would be the template for each PSC operated in their laboratory organization. They would accomplish this ambitious goal by using Lean and similar quality management methods to meet and exceed patient expectations.

Many pathologists and clinical lab managers might consider these goals to be overly ambitious. After all, phlebotomy services in general—and PSC operations specifically—can be ongoing headaches for lab managers.

This is true for two reasons. First, patients must often wait for extended periods of time before their specimens are collected. At the same time, when the phlebotomist is not skilled and/or lacks a good bedside manner, then the venipuncture—coming after an unwelcome wait—can make the patient’s experience at the PSC doubly unpleasant.

Second, phlebotomists who staff PSCs represent a distinct set of challenges for laboratory managers. Establishing a staffing schedule that properly matches when patients show up is an imperfect process. Often, the situation iscompounded by other factors, including turnover in phlebotomy staff, no shows, and phlebotomists with poor skills or work habits.

Thus, the decision at WellSpan Health to use Lean and process improvement techniques to create the “ideal” PSC was an ambitious undertaking.

“We wanted to create the ‘ideal’ floor plan for a patient service that would support the ‘ideal’ workflow in the PSC,” stated Steve Manzella, Ph.D., Technical Director of the Core Laboratory at WellSpan. “We would then remodel all our existing and new PSC facilities to conform to this physical layout.

“We expected two benefits from this accomplishment,” he continued. “One, it would measurably improve patient satisfaction. Two, it would give us optimal productivity and cost savings in the daily operation of our PSCs.”

However, for a laboratory organization committed to improving the patient experience and lifting patient satisfaction scores, there was another good reason to tackle this project. Recent patient satisfaction surveys conducted by WellSpan had identified areas where improvement by the laboratory could greatly enhance the patient experience. This made PSCs a rich target for improvement.

The Lean success story begins in 2009, after WellSpan Health did a system-wide customer satisfaction survey that included each of its two hospitals and all 13 of its patient service centers. These facilities are located in two counties in Pennsylvania.

Three Service Areas

“The patient satisfaction survey identified three service areas where our laboratories scored poorly,” stated Manzella. “It gave us firm data that we used to plan our improvement strategy.

“The first area involved communication; how our lab communicated information to patients and whether they received test results in a timely and understandable manner,” noted Manzella. “The second area involved coordination; this measured whether patients were told what personal information was needed prior to the visit and if they knew who to call if they had problems.

“The third area involved access,” he explained. “This evaluates how long patients waited, as well as whether they were told the reason for a delay.

“Because of the granularity of the survey information, it allowed us to see that our patients were having unacceptable issues with our service,” stated Tina Stover, MT(ASCP), who has administrative oversight of the patient service centers. Her colleague, Stephen Manzella, Ph.D., has technical oversight of the centers. Working together, they initiated a Lean project to: 1) understand the problems; and, 2) improve patient service.

“We operate two types of patient service centers,” observed Stover. “About half of our service centers have a traditional, two-step process. In step one, patients arrive and register at a reception window. In step two, the patients are then called for specimen collection.

“Our newer PSCs use a one-step process,” she said. “As the patient arrives at the PSC, he or she will be called back to a private room. Here is where both registration and collection happen.”

At the beginning of this Lean project, information about problems was collected. “We looked at patient complaints at each PSC,” stated Stover. “It was recognized that the majority of patient complaints involved wait times.

Pilot Programs in Two PSCs

“We then chose two PSCs, one of each type, that had significant complaints,” she said. “These sites were selected because we thought each could handle the disruption of the pilot improvement project.”

Armed with these findings, Stover and Manzella took steps to engage the support of WellSpan’s senior administrators. “We briefed the C-suite administrators about the problems and the goals of this Lean project,” she noted. “It was essential to have their support from the beginning.”

“Our administrators recognized the need to resolve these patient satisfaction issues,” added Stover. “Some had used our PSCs as patients themselves, so they shared with us both their good and their bad experiences. They recognized the ways in which we were struggling to achieve a consistent and top service at each PSC.”

Stover and Manzella next assembled the Lean team that would work on the project. Internally, WellSpan’s quality management department was brought in. To get external perspectives, BD Healthcare Consulting was engaged. “The lab staff selected to be part of this Lean team also included front line employees that were in regular contact with patients at the patient service centers.

Frontline Staff at PSCs

“To gather data, the Lean team did direct observation,” observed Stover. “Actual wait times were measured, as were door-to-door times. During this stage, one Senior Vice President spent two hours observing at one PSC. She wanted to fully understand the problems and see, first-hand, the patient flow at this site.”

Similarly, Stover and Manzella worked alongside frontline staff at the pilot PSCs so that staff could show them the “current state” work processes. “There is no substitute for getting hands-on with a Lean project like this,” said Stover. “Our Lean team was busy documenting problems, brain- storming solutions, and creating a list of action items.”

The Lean team quickly identified an issue that will be familiar to every laboratory that operates a patient service center. “Problem number one was that patients were waiting when the doors opened, but no one was ready to serve them!” recalled Stover. “That happened daily because the staff also arrived at opening time and weren’t ready to begin taking care of patients until several minutes after the official opening time.

Staffing Schedule

“This situation was further aggravated because full staffing at this PSC didn’t occur until two hours after opening,” she added. “It was obvious to the Lean team that this PSC was understaffed during its busiest time of the day!

“A second cause of delay in patient service turned out to be slow computers and printers. “During its observations, the Lean team recognized that PSC staff spent a lot of time watching the little whirling thing on the computer monitor, waiting for the computer to process the command,” she stated. “Once the computer had completed such a task, staff was then required to spend significant amounts of time walking back and forth to the printer and the label printer, because each PSC only had one of each.”

Ready access to supplies was identified as another problem. “The Lean team watched the amount of time staff in each PSC spent retrieving and replenishing supplies,” commented Stover. “This was a considerable source of wasted time.”

Upon completing direct observation and gathering data, the Lean team began evaluating new ways to re-design workflow and eliminate sources of waste and errors.

One immediate action was to change the way each PSC was staffed. “It seems obvious in hindsight,” noted Stover, “but we established a new schedule so that each PSC was fully staffed during its busiest hours.

“Another key improvement was implemented,” she continued. “Staff members were now scheduled to arrive 15 minutes before the opening time for the PSC. This allowed us to immediately begin serving the waiting line of patients, many of who wanted a quick blood draw so they could then leave to break their overnight fast by eating something.”

Each PSC’s existing hardware and software configuration was assessed by the Lean team. “Our IT staff tested and upgraded the existing computers,” said Stover. “Their goal was to increase speed. Additional printers and label printers were  purchased and installed in each collection room in the PSC.

“The additional printers not only reduced wasted time, but contributed to improved patient satisfaction in another way,” she noted. “Having a printer at the phlebotomist’s station made the process friendlier because the phlebotomist didn’t have to walk away and leave the patient alone. It also was validating to the staff to know that they were important enough to deserve their own printers.”

Work processes in each activity within the PSC were examined. The Lean team found numerous variations in how things were done. “The Lean team worked with the phlebotomists to design ‘standard work’ processes that reduced variation, eliminated waste, and made better use of staff time in each of the two prototype PSCs,” added Stover.

Developing “Standard Work”

“Training all the phlebotomists to perform ‘standard work’ comes with another benefit,” Stover said. “It allows us to more easily move staff between different patient service centers to fill gaps in staffing.”

Another simple improvement to work- flow significantly reduced patient wait times and improved phlebotomist productivity. “What the Lean team did was to assign a single individual in the PSC to be the ‘patient expediter.’ This person calls patients and then accompanies them back to the phlebotomy area,” noted Stover, “where the patient was either ushered into the collection room or—in our PSC of the older design—assigned to the chair where the collection would take place.

“Under our prior workflow, each phlebotomist would go to the waiting room door and call their next patient,” observed Stover. “Sometimes there would be a line of phlebotomists waiting at the door for their turn to call a patient.

Phlebotomists Waited in Line

“That meant the phlebotomists would all wait for the current patient to move from the reception area past that door before the next phlebotomist could call the next patient,” she continued. “While this might seem polite, it also meant that we had phlebotomists just standing and waiting. And, don’t forget, many patients are infirm, elderly, or using walkers. That means their walk to the door can be quite slow.

“The Lean team came up with a different workflow, based on having one phlebotomist utilize two rooms or two chairs,” commented Stover. “In this arrangement, when they finished with one draw, the phlebotomist could walk over to the other room, or to the other chair where their next patient was waiting, and get ready for the collection.

“Meanwhile, our patient expediter in the reception room would fill that now-empty room or chair with the next patient,” she said. “Initially, some phlebotomists didn’t like this workflow arrangement. But once they saw its value in reducing patient wait times, they liked this improvement.

“Quick feedback was the strategy our Lean team used to implement these types of workflow improvements,” recalled Stover. “The phlebotomists in the PSC were asked to try this new workflow for an hour and see how things went. Staff members were amazed how quickly the PSC’s waiting room cleared out.

“We learned that quick feedback is very powerful in reinforcing these types of changes,” said Manzella. “Some Lean projects are easier to get going than to keep going. You need the reinforcement of quick feedback to sustain the successes of these Lean projects.”

“Feedback in the form of follow-up customer surveys is another way to reinforce the value of new processes,” noted Stover. “Our phlebotomists valued the positive customer comments. It was an affirmation that patients recognized the changes and liked them.

“Don’t forget, many of these patients are regular visitors to a PSC,” she added. “The ongoing relationships patients have with PSC staff add extra credibility to the comments they make in the follow-up patient satisfaction surveys.”

Another strategy that turned out well for Manzella and Stover was the use of a Lean consultant. “As an outside consulting firm, with experience in many different laboratories, they can make suggestions or reinforce the proposed workflow redesign improvements in ways that staff will more readily accept, than, say, if these same suggestions came from our internal Lean team,” observed Manzella.

Of course, the value of any Lean improvement project is how it changes the core metrics used to monitor service levels, staff productivity, and reduced costs. “To establish base-line data prior to starting this Lean project, the staff gathered data over about four days,” noted Stover.

“At one PSC, they clocked average patient wait times at 20 minutes,” she recalled. “Two days after changing work processes and overall workflow, the Lean team again collected data. Based on an observation of the new workflow for three consecutive days, they determined that patient wait times had dropped to an average of 11 minutes. That was a 45% improvement from a relatively simple and easy-to-implement Lean workflow redesign in our patient service center.”

By the end of the pilot project, the two sites had dramatic improvements in both wait times and door-to-door times. At the site using the traditional two-step process, average wait times dropped from 20 minutes to five minutes, a 75% decrease, while door-to-door times dropped from 32 to 13 minutes, a 59% decrease.

At the one-step patient service centers, average wait times dropped from 10 minutes to two minutes, an 80% decrease, and door-to-door times dropped from 21 minutes to 13 minutes, a 38% improvement.

Manzella emphasizes that maintaining the changes will mean constant feedback to keep staff aware of their affect on the customer experience. “Now, when we get a positive customer comment, a senior staff member personally shares that comment with the employee in front of his or her peers. And we post individual site statistics weekly so that staff can see how they are doing.”

Lean Improvement Projects at Phlebotomy Sites Cut Wait Times and Boost Patient Satisfaction

At WellSpan Health in York, Pennsylvania, Lean teams in the clinical laboratory set out to identify the “ideal” floor plan for a patient service center (PSC), along with the “ideal” standard workflow. As this was accomplished, patient wait times were reduced by 80% in the one-step PSCs and 75% in the two-step PSCs. As a result, patient satisfaction surveys recorded a big increase in patient satisfaction scores for the laboratory.

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Minimal Capital Required to Create Changes in PSCs

EFFORTS AT WELLSPAN HEALTH TO DEVELOP an “ideal” PSC floor plan and workflow did not require much of an investment. “We spent some money to upgrade the computer and install additional printers,” said Tina Stover, Operations Manager, Laboratory Services. “Our only other expense was to install a ‘nanny-cam’ in the waiting room.

“The image from this camera is displayed in the corner of each phlebotomist’s computer screen,” she explained. “This allows the phlebotomists to monitor the number of patients waiting in reception at any point during the day.

“That nanny-cam was a solution to the problem that happens in many PSCs during slow periods,” commented Stover. “During a slow time, it is easy for phlebotomists to get distracted as they refill supplies or do other catch-up tasks. They can forget to check the waiting room. Now they can continuously monitor patients in the reception area.”

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