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Clinical Laboratory Strategies: January 28, 2010

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Improving Patient Satisfaction with the Lab
Lean Principles Help Streamline Phlebotomy
By Bill Malone


Multiple studies have been published on applying Lean production principles to labs, but so far, researchers have focused on specimen processing and not phlebotomy. A recently published study found that using Lean in outpatient phlebotomy dramatically improved patient satisfaction and workflow. The findings are the subject of this issue of Strategies.

Derived from the Toyota production system, Lean principles aim to eliminate non–value-added steps and waste through management techniques such as continuous improvement, called Kaizen. Given the finite resources available to labs, be it labor or money, Lean has proved to be an attractive and successful strategy. Now, researchers at Brigham and Women’s Hospital in Boston have pushed this idea outside the core lab to outpatient phlebotomy, a venue that is the face of the lab to patients and where patient satisfaction plays a huge role (Am J Clin Pathol 2009;132:914–919).

“For the clinical lab, phlebotomy is the area where you’re actually interacting with patients, and one of the things we pride ourselves on is good customer service,” said Stacy Melanson, MD, PhD, associate medical director of chemistry in the department of pathology, clinical laboratory division at Brigham and Women’s Hospital, and the lead author of the study. “We are very pleased that this process allowed us to increase patients’ satisfaction so significantly without needing a lot of extra staff or resources.”

In fact, the 4-day Kaizen event performed under the study has brought the patient wait time in Melanson’s phlebotomy station to less than 5 minutes, down from an average wait time of 21 minutes before the event. Surveys also showed that patient satisfaction improved by 50% for questions about the length of the wait and how well they were kept informed. “It was surprising that seemingly simple changes made such a huge impact,” said Melanson. One of those changes popular with patients is a deli counter-style numbering system. Patients receive a number to indicate their place in line, with the number of the last patient called clearly displayed. A sign also informs patients of the hours of operation and the lab’s busiest periods. This way, patients know how many people are ahead of them, and if they chose, they may return during a slower period. “I think people like to know where they are,” said Melanson. “If they know there are eight people ahead of them, they’re prepared for that. We can all relate—you want to know, is it going to be five minutes, or an hour?”

Another improvement that bumped up patient satisfaction according to the surveys was modifying the urine collection procedure. Whereas before, patients would wait until after their blood was drawn to provide a urine specimen, now patients are given the option to produce the specimen while they wait, reducing their overall time at the lab by an average of 20%.
Other changes centered on staff operations and eliminating non-value-added tasks. These included a redundant double-checking of specimens before they were sent to the lab, logging when canisters of samples were sent via pneumatic tube, and answering the phone for general laboratory-related questions. “We found that before we improved the answering system, they were answering the phone for general lab questions simply because someone would call the wrong department,” explained Melanson. “They were wasting time on the phone just trying to transfer calls to the right place.” Insights from the Kaizen event also lead the team to switch from a system were each phlebotomist called his or her own patients to having one coordinator designated each day to greet patients and smooth the workflow.

These changes may seem rather obvious, but it was the Kaizen event and the ensuing cultural shift that made the problems visible in the first place and then fixable without a lot of expense, emphasized Melanson. “All the improvements make perfect sense in hindsight, but we needed the dedicated time, resources, and involvement of front-line staff to make it happen,” she said.
Before the Kaizen event, Lean leaders from the Brigham and Women’s Hospital’s own Center for Clinical Excellence formed a committee along with lab staff to set broad goals for the process. They also received Lean training from GE Healthcare Performance Solutions of Chalfont St. Giles, U.K. The committee studied all the phlebotomy station’s processes and identified areas that needed improvement, eventually deciding to focus their objectives on patient wait time and overall satisfaction.

The Kaizen event itself took the shape of an intensive but structured 4-day workshop where staff brainstormed then tested Lean strategies in real time, which meant adding some extra staff on those days so that normal operations could continue while the Kaizen team worked. The team included four phlebotomists, one chemistry medical technologist, and one laboratory technician. “This was important so that, collectively, we had an idea of how the entire process of the lab was involved,” said Melanson. “Even though we were focused on the phlebotomy station, we were working with samples that went through lab processing and ultimately ended up in clinical chemistry.”

Day one of the Kaizen event focused on educating the front-line staff about Lean principles; on day two, the team identified solutions; and on days three and four, the team tested and measured the implementation of their ideas. Process improvement continued after the event, with updates on how well staff were meeting their goals and “huddles” within the work area every few days. Formal monthly meetings now continue to keep the team on track and continually incorporate new ideas from staff, one of the core concepts of Kaizen. “The real purpose of Kaizen is continual improvement, and the people who drive that improvement are the front-line staff,” said Melanson. “This means changing cultural thinking that everything should be from a top-down management structure, and instead, empowering your staff to make suggestions and changes to the process.” Though the response from the phlebotomy staff was overwhelmingly positive, Melanson pointed out that the leadership worked daily to congratulate staff on their successes, offering specific examples of how the staff contributed to patient wait time or satisfaction.

For other institutions looking to use lean, Melanson advised laboratorians to make sure that both the leadership and staff get trained in the process to make sure they really understand it. Also, management support is important to empower front-line staff to continue working on improvements. Finally, do your homework. As the authors state in the article, their 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.”

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