CEO SUMMARY: In the 1990s, many hospitals implemented decentralized phlebotomy arrangements as a way to save costs. Now, a decade later, centralized phlebotomy, managed by the laboratory, is making a comeback. Motivation for this unfolding trend is the need for hospitals to improve patient safety and increase patient satisfaction. Because most patients are uncomfortable with venipuncture, phlebotomy is often mentioned in satisfaction surveys and hospital administrators are taking active steps to change that situation.
IN A SURPRISING TURN OF EVENTS, hospital administrators are paying increased attention to phlebotomy services. This heightened interest in phlebotomy is a direct consequence of the twin trends of improving patient safety and closer tracking of patient satisfaction.
Blame it on The Joint Commission (JC–formerly JCAHO) and new accreditation requirements. In recent years, The Joint Commission has made it important for hospitals to more intensely survey patient satisfaction—then use this information to craft specific programs to raise patient satisfaction scores before the next accreditation inspection.
As hospitals responded with more detailed patient satisfaction surveys, phlebotomy began to surface as a source of patient dissatisfaction—and as a corresponding opportunity to improve the experience and satisfaction of patients when they visit the hospital. This has put phlebotomy square on the radar screen of hospital administrators.
In the search for ways to improve, a number of hospitals are reconsidering centralized phlebotomy versus decentralized phlebotomy. A decentralized model is one in which a number of medical professionals can draw blood and collect specimens from patients throughout a hospital. A centralized model is one in which the laboratory supervises phlebotomists, whose primary responsibilities are to draw blood and collect specimens.
Advocates of centralized phlebotomy observe that decentralized phlebotomy can be costly, can cause needless delays in specimen processing turnaround times, can result in poor blood draws, and sometimes contributes to errors in patient care, such as from misidentified specimens.
“Contrast that with an efficient centralized model in which phlebotomists report to—and are supervised by—laboratory directors or other laboratory staff,” said Keith Nelson, Administrative Director of Laboratory and Dialysis at Silver Cross Hospital in Joliet, Illinois. “This approach to phlebotomy can save a hospital significant sums of money, since it can be more efficient than the decentralized model.”
At 304-bed Silver Cross Hospital, Nelson estimates that centralized phlebotomy saves $400,000 just in annual labor costs—in addition to improving quality and patient satisfaction. Nelson has written extensively on this subject. He did a study for his hospital which compared the efficiency of the former decentralized phlebotomy model with a centralized model. He found startling differences between the two.
Large Number Tasked To Draw
“When we looked at the hospital’s decentralized model, we identified a large group of clinical lab assistants who would draw blood,” Nelson says. “In this hospital model, a clinical lab associate can draw blood, weigh patients, take their temperature, change beds, and do many other tasks related to patient care.
“From a quality standpoint, this method is very difficult to manage because a large group of 150 people are involved in drawing blood and collecting samples,” he explained. “The chances of these 150 people performing every venipuncture in a high quality manner are not good because of the challenge of maintaining the competency of such a large group of people.
“Further, in a decentralized setting, the art of acquiring blood is not the main goal of the people doing this job,” Nelson added. “So, we might get early morning blood samples drawn any time in the morning and these can have negative consequences for turnaround time.
“On the other hand, with a centralized phlebotomy system, samples flow into the laboratory quickly every morning, allowing results to post back to the charts by 8 a.m.,” he noted. “Once our hospital converted to centralized phlebotomy, we improved our aver- age turnaround time for posting results on the chart by as much as two hours. That’s a significant difference.
“Decentralized phlebotomy is associated with a high rate of redraws,” continued Nelson. “Under this arrangement, there were months when we needed to redraw more than 100 patients. It’s no secret that patients hate to be redrawn, and that redraws are costly, inefficient, and time consuming. In the centralized approach, the team of professionally trained phlebotomists dramatically reduces the number of redraws.
“The other primary source of improvement from centralized phlebotomy are the savings in labor,” added Nelson. “In a decentralized model, you might have two clinical lab associates on each unit. But these are not trained phlebotomists under the supervision of the lab. So, they are often busy with any number of other jobs. If one of those two associates calls in sick and the other one has to take over their duties, then this unit has a 50% absence rate, along with less ability to respond with timely blood draws.
“In the case of a centralized phlebotomy service and core group of 10 phlebotomists, when one individual calls in sick, the absence rate is only 10%,” he noted. “In this situation, it is much easier to maintain a high quality of service and efficiency, while sustaining target turnaround times and throughput rates.
Only 29 People Needed Now
“At the time I did this study, our hospital’s decentralized phlebotomy system was using a group of about 150 people to draw blood all over the hospital,” he said. “When the lab took over responsibility for blood draws and instituted centralized phlebotomy, we required only 29 people.
“We got to that number by attrition, which is how the $400,000 in annual savings was realized,” stated Nelson. “Plus, our 29 phlebotomists not only draw blood, but also do IVs and EKGs. We were so efficient that we were able to take on these additional duties.
“Over the past few years, the focus on patient safety is having an effect on phlebotomy. The pendulum seems to be swinging back toward centralized phlebotomy because of issues related to patient satisfaction and quality care,” he said. “Before this latest trend, there was a move toward decentralized phlebotomy.
“But how many times does a patient want to get stuck when the person taking the sample is not well trained?” asked Nelson. “There’s less tolerance for poor care today. Further, with the decentralized model, we had a lot of incorrect patient draws and even misidentified specimens. These types of events can lead to serious patient errors and lawsuits.”
Progress At NCH Health
Another health system that returned to a centralized phlebotomy service, managed by the laboratory, is NCH Health System of Naples, Florida. In 1996, NCH instituted phlebotomy-specific training to address a number of recognized problems. Then, in 2002, it introduced a centralized phlebotomy program as a way to pursue further improvements in patient care and patient satisfaction.
The goal of both initiatives was to raise the level of quality of phlebotomy services and patient satisfaction. “Both efforts helped to improve results markedly,” said Helen Ogden-Grable, Laboratory Clinical Educator for NCH Health System.
“In the fall and winter of 1995 and 1996, the NCH hospitals had an unacceptable number of rejected blood specimens and a high rate of blood culture contamination,” she said. “Further, phlebotomists perform an invasive procedure. They have to realize that they hold the happiness and satisfaction of the patient in their hands.”
To raise performance and improve patient satisfaction, NCH Health System instituted a phlebotomy training class program in 1996. “Because of these classes, we saw immediate improvement in many areas,” reported Ogden-Grable.
“Our training program runs for seven weeks. Each participant needs 80 hours of didactic classroom training and 120 hours of clinical rotation,” Ogden-Grable explained. “During the rotations, the phlebotomist in training is never alone with a patient. Each one works with a mentor and must do 100 observed venipunctures before he or she can work independently.”
To measure patient satisfaction, NCH Health Systems uses survey company, Press Ganey Associates, Inc., in South Bend, Indiana. “We mail surveys to patients following their hospital stay,” said Ogden-Grable.“On these surveys, the hospital lab is graded on two factors: the technique of the person taking the blood sample and their level of customer service, meaning their communication with the patient.We consistently score very high on both measures.
“What’s more, the patient satisfaction scores reflect on the entire laboratory because the people in the laboratory never meet a patient,” Ogden-Grable explained. “Our phlebotomists are the ambassadors for the laboratory. They make a positive impression on the patient and that’s what the patient remembers about his or her lab experience.
“It sounds simple to take a blood sample and put it in a tube, but there is much more to it than that,” she said. “It involves establishing rapport with the patient, having compassion, treating every patient the same, and following all the required procedures, including identifying the patient properly, using the correct technique, and taking the sample from the proper vein. The patients are going to let us know through our satisfaction surveys when we don’t deliver the best patient care.
“We also go one step beyond the mail surveys,” Ogden-Grable added. “We utilize an internal random patient survey system. Our lab directors, the phlebotomy supervi-sor, the lead phlebotomist, or the clinical educator can meet with patients and go through a checklist. This lets us know how they feel about blood collection.
“By doing these random surveys, we discovered important issues that help us coach the staff to do a better job,” Ogden- Grable continued. “We can use the information from the patient when we meet with the phlebotomist and explain how they can improve.
Reflecting Lab Quality
Since implementing a centralized phlebotomy service in 2002, other responsibilities have been added. “Here at NCH, we have an IV Start Phlebotomy Team,” Ogden-Grable said. “We have nine senior phlebotomists, any of whom can be asked to do IV starts. It’s unusual to have a team like this, but any patient getting an IV wants someone who knows what they’re doing. Nurses were happy that we implemented this start team because our senior phlebotomists are experts at finding veins.
“Some of the best hospitals in the country, such as the Mayo Clinic, have vascular access teams or a team of phlebotomists who do IV starts as we do,” she added. “We have very high patient satisfaction scores as a result of our IV start team and the trained phlebotomists.”
New Guidelines Get Results
THE DARK REPORT observes that it is no accident that phlebotomy services are getting increased attention by hospital administrators. This is a direct result of the changing accreditation guidelines, which, themselves, are steps to reform the American healthcare system.
It shows that, not only are some healthcare reform efforts catching the attention of hospitals and other providers, but they are triggering responses that lead to improved care and greater patient satisfaction. Hospital administrators are paying closer attention to phlebotomy services and devoting more money and resources to improving the performance of phlebotomy because it directly improves the patient experience. This is not news to laboratories, because they recognize how many people are uncomfortable with venipuncture. Labs also know how angry doctors can become if the patient complains about a poor or painful blood draw.
The next intelligence briefing on phlebotomy services will profile a booming sec- tor of phlebotomy and laboratory medicine that represents an unlikely range of products attracting hospital dollars—and all designed to improve the patient’s experience during venipuncture.
Decentralized Phlebotomy Fails to Deliver Improved Quality and Patient Satisfaction
“IT WAS A MOVE TO CUT COSTS that motivated many hospitals to shift phlebotomy to the nursing staff in the 1990s,” said Dennis Ernst, Director of the Center for Phlebotomy Education, Inc., in Ramsey, Indiana. The center develops educational materials for healthcare professionals responsible for blood specimen collections.
“Today, hospitals recognize that laboratorians and trained phlebotomists are better suited to collecting blood samples from patients,” Ernst commented. “But back in the 1990s, there was a trend of moving responsibility for blood draws to the nursing staff. That trend has proven to be a miserable failure because of poor patient satisfaction scores.
“Unfortunately, it has taken five to 10 years for hospital administrators to realize that decentralized phlebotomy was a mistake,” noted Ernst. “Starting in 2000, laboratories began fighting to get back responsibility for phlebotomy.
“When phlebotomy is decentralized, hospitals have customer service problems,” he continued. “Research shows decentralized phlebotomy results in more mislabeled laboratory samples reported and an increase in unacceptable specimens, including hemolysis.
“When non-laboratorians draw blood, they often don’t pay as much attention to detail because they don’t appreciate how the accuracy of the test result is a function of collecting the sample properly,” explained Ernst. “Since it is widely known that patients are less satisfied when non-laboratorians are drawing specimens, there are many reasons why a lab manager would want to reclaim responsibility for phlebotomy services.”
Predict that Phlebotomists Will Help Point-of-Care Testing
THERE IS A SIGNIFICANT TREND developing in point-of-care (POCT) testing that is likely to affect phlebotomy technicians.
“In the next five to 10 years, phlebotomists will start to get involved in point-of-care testing because more tests will be done at the bedside and that’s a perfect role for the phlebotomist,” said Keith Nelson, Administrative Director of Laboratory and Dialysis at Silver Cross Hospital in Joliet, Illinois.
“This is likely to be a natural opportunity as point-of-care testing becomes more cost-effective and bedside testing kits for a greater number of conditions become available,” noted Nelson. “The phlebotomy profession is well-placed to perform point- of-care testing, under the supervision of the laboratory. Among other reasons, phlebotomists are trained to collect a quality specimen. They understand how the sensitivity and specificity of the test can be affected by the quality of the specimen.”