OUP user menu

Applying Lean/Toyota Production System Principles to Improve Phlebotomy Patient Satisfaction and Workflow

Stacy E.F. Melanson MD, PhD, Ellen M. Goonan MS, MT(ASCP)SH, Margaret M. Lobo, Jonathan M. Baum MBA, José D. Paredes MS, Katherine S. Santos, Michael L. Gustafson MD, MBA, Milenko J. Tanasijevic MD, MBA
DOI: http://dx.doi.org/10.1309/AJCP7FIKZVVTFTXQ 914-919 First published online: 1 December 2009

Abstract

Our goals were to improve the overall patient experience and optimize the blood collection process in outpatient phlebotomy using Lean principles. Elimination of non–value-added steps and modifications to operational processes resulted in increased capacity to handle workload during peak times without adding staff. The result was a reduction of average patient wait time from 21 to 5 minutes, with the goal of drawing blood samples within 10 minutes of arrival at the phlebotomy station met for 90% of patients. In addition, patient satisfaction increased noticeably as assessed by a 5-question survey. The results have been sustained for 10 months with staff continuing to make process improvements.

Key Words:
  • Lean
  • Phlebotomy
  • Specimen collection
  • Process improvement
  • Clinical laboratories

The health care system in the United States is frequently criticized for waste, inefficiency, and medical errors.1 To address these concerns, several institutions have used Lean principles to improve workflow and capacity and increase patient and employee satisfaction.2 Lean is derived from the Toyota Production System, which emphasizes the elimination of waste and non–value-added steps in a setting of limited resources, eg, money, space, and human capital.3,4 Kaizen, which means continuous improvement, events are one method to apply Lean principles to a process or setting. Occurring over 4 days, a Kaizen event brings together front-line staff members, who are experts in the process, to brainstorm issues, identify solutions, and iteratively test ideas in the work area in real time. Successful tests are further refined and incorporated as part of the standard work.

Brigham and Women’s Hospital (Boston, MA) is a 777-bed teaching affiliate of Harvard Medical School (Boston) with approximately 46,000 admissions per year and 1 million outpatient visits. The clinical laboratory provides phlebotomy services for inpatients and outpatients. There are 5 on-site locations for outpatient blood draws. The primary outpatient phlebotomy area draws samples from an average of 190 patients and obtains 500 specimens per day during the week. It is staffed by 8 phlebotomists and operates between the hours of 7:30 am and 6:00 pm.

The clinical laboratory leadership selected the main outpatient phlebotomy laboratory to undergo Lean process improvement through a Kaizen event owing to its large volume of patients and specimens and its direct impact on patient care. Our objectives were to improve patient satisfaction and reduce patient wait time. This article outlines the process, details its impact on workflow and patients, and offers suggestions for laboratories embarking on similar process improvement projects. This is one of the few articles describing the use of Lean principles in phlebotomy.

Materials and Methods

Preimplementation Work

With assistance from a group of trained Lean leaders from the Center for Clinical Excellence (CCE) at Brigham and Women’s Hospital, we chose outpatient phlebotomy as an area to apply Lean principles during one of several Kaizen events conducted in the clinical laboratories. We formed a multi-disciplinary Process Improvement Leadership Committee composed of clinical laboratory and CCE staff, all of whom were given Lean training from GE Healthcare Performance Solutions (Chalfont St Giles, England). The Leadership Committee was charged with determining the objectives and scope for the Kaizen event. Before the process improvement, we also ensured that other departments, such as information technology and engineering, would be available to assist in real time with any technical and operational changes.

An essential element of Lean is the central role of front-line staff. It reflects the belief that the people directly involved in the daily work are best equipped to evaluate and determine what changes are needed. Therefore, appropriate personnel were selected from existing staff, and schedules were rearranged to allow them to have dedicated involvement in the process. A timeline and sequence for the process improvement events were defined. Before the actual Kaizen event, the existing processes were examined from patient arrival to patient departure from the phlebotomy location. Each stage of patients’ experience was observed to understand the causes for delays or prolongation of a patient visit. The following preimplementation metrics were collected: patient volume by hour and day of the week; staffing by hour and day of the week; and patient wait time. Patient wait time was measured from 8:00 to 11:00 am during peak hours when the most patients were seen. In addition, patient satisfaction was assessed using a 5-question survey that asked about the courtesy and skill of phlebotomists and the length of their wait. Patients were instructed to respond to the questions on a 5-point Likert scale (excellent, very good, good, fair, or poor).

The data were used by the Leadership Committee to validate and refine the process objectives. The following goals were set: (1) 50% or greater improvement in patient survey results for questions regarding the length of the patients’ wait and how well they were kept informed and (2) at least a 5-minute reduction in patient wait time, with 90% of patients waiting no longer than 10 minutes. The leadership team charged the Kaizen team with applying Lean principles to each of the phlebotomy processes, including eliminating nonessential work functions, improving the efficiency of non–blood-drawing activities, reordering process steps, and changing accessioning workflow. However, the leadership team placed constraints and asked that minimal additional resources or expenditures be used and that the caliber of service be preserved or improved.

Kaizen Event

A multidisciplinary Kaizen team was chosen to participate in the 4-day Kaizen event and included 4 phlebotomists, 1 chemistry medical technologist, and 1 laboratory technician. The Kaizen team was led by the Lean leaders from CCE. Day 1 consisted of a kickoff by the sponsors, review and validation of improvement opportunities, and education on Lean principles. On day 2, the team identified and selected solutions and developed Plan-Do-Study-Act (PDSA) test plans. The PDSA method is an iterative testing approach that includes planning the test, conducting it, observing, and measuring the results. These plans allowed the team to begin testing and measurement on day 2. The third and fourth days consisted of making modifications to the tests as necessary and continued measurement to study the results. Because testing was taking place in the live setting, communication and sustain plans were developed. On the last day of the event, testing and measurements were completed, standard operating procedures were updated, and a 30-day action plan was created. At the end of each day, the team presented its progress to the leadership team members, who gave their feedback and support.

Continuing Improvement

Process improvements continued after the Kaizen event was concluded, and leaders and front-line staff continued to use Lean principles under the guidance of Lean leaders as necessary. The average patient wait time and percentage of patients meeting the wait time goal were tracked and distributed to staff weekly. Patient satisfaction surveys were reassessed several months after completion of the Kaizen. Brief meetings (or “huddles”) were also conducted within the work area with staff every 2 or 3 days. This allowed participants to quickly assess how well changes were being sustained and evaluate if modifications were needed. More formal meetings were convened weekly for the 30 days immediately following the event and now continue on a monthly basis. This allowed staff and management to ensure that all action items from the Kaizen event were being completed.

Statistics

To evaluate the variability in patient wait after the Kaizen event and assess whether an improved stable process was achieved, process control charts were generated.57 Specifically, X-bar and S charts appropriate for continuous data with subgroups of variable sizes were created. The X-bar represents the average patient wait time and the S chart represents the standard deviation. Upper and lower control limits were calculated based on 3 σ limits.57 Process control charts allow distinguishing between variation due to common causes and variation due to special causes. A process is considered stable when there is “random distribution” of plotted points within the control limits. Variation due to special causes is evident when points fall outside the control limits.

Results

Kaizen Prework

The existing workflow was documented Figure 1 . The following opportunities were identified during the pre-work period: (1) Non–blood-drawing activities decreased the amount of time phlebotomists could devote to their patients. (2) Patients often arrived before the opening of the phlebotomy station, creating a backlog at the beginning of the day that increased wait time. (3) Because patients were not aware of their “place in line,” staff sometimes had difficulty identifying and finding the next patient when it was his or her turn. Before our process improvement initiative in outpatient phlebotomy, the average patient wait time during a high-volume period was 21 minutes (± 3 minutes). A pre-Kaizen patient survey was completed by 34 patients, and an average of 56% of responses were “excellent” or “very good” Figure 2 . Patients were least satisfied with being informed about the wait time and the length of wait.

Figure 1

Phlebotomy workflow before Kaizen event and application of Lean principles.

Figure 2

Patient satisfaction survey results. The percentage of patients responding excellent or very good to each of the 5 questions pre-Kaizen (white bars), at the end of the Kaizen (gray bars), and 5 months after the Kaizen (black bars) is plotted.

New Lean Workflow and Kaizen Event

One of the first changes we introduced was a numbering system. All patients were given a number indicating their place in line. Because the number of the last patient called was clearly displayed, arriving patients would also know how many people were ahead of them. The sign also showed the laboratory hours and the busiest periods so that patients could return at a slower or more convenient time of their choosing.

We increased phlebotomists’ available draw time by eliminating non–value-added tasks or modifying existing tasks Table 1 . Furthermore, to improve efficiency during peak hours, requisitions for standing orders were copied the night before patient arrival. Because having every phlebotomist call his or her own patients into the drawing area was inefficient and time-consuming, a result of the Kaizen was to have 1 phlebotomist each day assigned as the workflow coordinator or “greeter.” The workflow coordinator increased efficiency, greeted the patient to provide a more personalized environment, and was available throughout the process to answer questions.

In addition to these operational changes, the urine collection procedure was modified. Before the improvement event, patients typically provided a urine specimen after having their blood drawn. However, offering patients the option of producing a urine specimen while they waited served to decrease their total time spent in the laboratory. The phlebotomist workspace was also reorganized to improve workflow. A representative from the engineering staff was available to address any structural questions about the workspace.

Improved Metrics

The average wait time decreased from 21 minutes (± 3 minutes) to 11 minutes (± 5 minutes) for all patients during the event. The different workflow before the Kaizen event contributed to long wait times; these may have included patients arriving without required information such as clinician identification or diagnosis. Collecting urine specimens before the blood draw helped decrease wait time. For patients requiring urine collection, the wait time was reduced by 20%. The percentage of time spent performing non–value-added tasks decreased, which also contributed to shorter wait times. Since the Kaizen event, the average wait time has decreased to less than 5 minutes and has been maintained at this level for the last 5 months Figure 3 .

The X-bar chart shows that in the first few months after the Kaizen event, a number of points fell outside the control limits, which was most likely due to holidays and adjustment to the new workflow (Figure 3A). Starting on October 20, the patient wait times shifted downward, and the following 23 consecutive points were below the original lower control limit. This indicated a special cause variation and an improved stable process as a result of the Kaizen event, changes in the staffing model in October, and other workflow changes. The S chart mirrors the special causes seen on the X-bar chart (Figure 3B). The charts were redrawn starting October 20 to reflect the new control limits and illustrate 2 distinct processes. The new process shows less variability, and the central tendency is approximately 70% lower (13 to 4 minutes) on the X-bar and 40% lower (7.02 and 4.28 minutes) on the S chart compared with the old process. Beginning on February 2, there was further evidence of the continued downward trend in both X-bar and S charts.

The level of consistency that phlebotomy achieved also improved. Following the Kaizen event, the percentage of patients waiting 10 minutes or fewer varied from as low as 20% to as high as 80%. This variability was due to multiple factors, such as staffing that did not match patient volumes throughout the day, break schedules, and hours of operation. These issues were resolved over time, and during the last 5 months, this percentage has consistently been between 80% and 90% Figure 4 . The amount of time it took phlebotomists to physically collect specimens did not change before and after the Kaizen event, suggesting that the shorter and more consistent wait times could be attributed to process improvement and reduction in non–value-added steps.

View this table:
Table 1
Figure 3

A, X-bar process control chart. The average patient wait time for a morning in the beginning of each week (diamonds, black line) is plotted. Upper (red line) and lower (green line) control limits and the central tendency (dotted black line) are shown. B, S-chart. The standard deviation of the patient wait times (diamonds, black line) is plotted for each day data were recorded. Upper (red line) and lower (green line) control limits and the central tendency (dotted black line) are shown.

Figure 4

The percentage of patients meeting the wait-time goal. The goal of 90% of patients waiting 10 minutes or less is shown by the solid straight line. The percentage of patients achieving this goal for a morning in the beginning of each week is plotted (diamonds, solid line).

Patient satisfaction was assessed at the end of the Kaizen event (n = 50 patients) and 5 months after the Kaizen event (n = 33 patients). An average of 86% of patients responded “excellent” or “very good” at the end of the Kaizen event (Figure 2). In particular, responses to questions regarding the length of the patients’ wait and how well they were kept informed improved by approximately 50%, which was consistent with our goal. These results were sustained as illustrated by the 5-month post-Kaizen survey (Figure 2). In addition to the patient survey, comments on the new and old process were obtained from staff and patients that illustrated improved quality and efficiency. Some patient comments after the Kaizen event were “felt more organized,” “efficient and well run,” and “liked having a first-come first-served system and knowing place in line.”

Discussion

In the setting of decreasing availability of technical staff, complaints about work-related stress, increasing test menu, and limited space, pathology departments and clinical laboratories are asked to improve turnaround time and expand services while reducing cost. Lean principles can be applied to achieve these objectives, and a few organizations have published their experiences.3,812 However, most institutions focused on specimen processing within the clinical laboratories.812 In particular, they implement a single-piece workflow, as opposed to batch workflow, to distribute the workload more evenly. A limited number of articles discuss the redesign of specimen collection processes to achieve improvements.9,11 In this article, we describe our experience and use of Lean principles to improve outpatient phlebotomy workflow and patient satisfaction.

Our Lean process improvement initiative has shown significant and sustained improvement in patient satisfaction and workflow efficiency in outpatient phlebotomy. Although this required a significant time commitment from leadership and staff, all improvements were made without additional staffing or space and with minimal budget resources.

Successful application of Lean principles has led to additional improvements since the initial Kaizen event. Several modifications were made to the staffing model to allow increased availability of phlebotomists during peak hours (8:00–11:00 am). The break schedule was shifted from the morning to afternoon, and staff schedules were modified to increase the number of staff working during the first 2 hours of the morning. In addition, the opening of the laboratory was moved from 8:00 am to 7:30 am to accommodate patients with early clinic appointments. A rarely used fifth phlebotomy chair was replaced with one that had similar functionality to the other chairs to increase drawing capacity by 20%. Finally, the patient experience was improved by increasing the number of chairs in the waiting area. These additional changes contributed to the improved and sustained process that is illustrated in the process control charts.

Throughout the process we gained several insights into Lean process improvements that may be helpful to other hospitals or organizations considering implementation of Lean. Our experience has illustrated the significant amount of work and organization that is required for success. Changes to the systems and structures, as well as to the culture of the department and institution, must occur to support improvement work like Lean. It is important to have management support throughout the process, especially to empower front-line staff to continually identify opportunities for improvement and to celebrate the successes of the implemented improvements. We also found it useful to have key areas of the hospital, such as engineering, available to make changes in real time.

We continue to use Lean process improvement techniques throughout the department. We have subsequently completed 3 more Kaizen events in specimen processing and clinical chemistry. They have also yielded improvements to operational processes and positively impacted patient care. The Lean culture has also expanded to other departments, resulting in improved services hospital-wide.

Acknowledgments

We thank the entire Kaizen event team (Linda Crane, Lidia DeMartino, Yamil Garcia, Nadege Michaud, Telisha Morris, and Donovan Wallace) for their creative ideas, hard work, and ongoing commitment to Lean and process improvement.

Notes

Upon completion of this activity you will be able to:

  • describe Lean/Toyota production system principles.

  • apply Lean principles to the clinical laboratory.

  • discuss how to conduct and monitor Lean process improvement.

The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The ASCP designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™ per article. This activity qualifies as an American Board of Pathology Maintenance of Certification Part II Self-Assessment Module.

The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Questions appear on p 973. Exam is located at www.ascp.org/ajcpcme.

References

  1. 1.
  2. 2.
  3. 3.
  4. 4.
  5. 5.
  6. 6.
  7. 7.
  8. 8.
  9. 9.
  10. 10.
  11. 11.
  12. 12.
View Abstract