Something interesting happens when you start revising the processes of your laboratory. Even when you think you have streamlined the work flow a great deal and eliminated activities that slowed things down, you will suddenly notice other areas to improve that you never would have seen before. This is exactly what happened in the Medical Center Laboratory at Jackson-Madison County Hospital, the flagship facility of West Tennessee Healthcare in Jackson, Tenn. It was only after the lab greatly improved its processes that the staff noticed one specific new way they could make things better.
A Work in Progress
“As an organization, we had already entered in what we called lean management processes that changed everything we did in our laboratory,” says Jamie Boone, MT (ASCP), assistant director of lab services for Medical Center Laboratory, which employs 190 people.
Specifically in the area of phlebotomy, Boone explains, the staff had already closely studied the processes involved and made some major changes. First, they determined what “nonvalue-added activities” were slowing the process down. They found that a great deal of time was spent sorting labels for tubes and that phlebotomists often had difficulties with their carts, which could be organized and stocked in a variety of ways. One of the first changes the lab made was to standardize the phlebotomy carts, “so when you went out on the floor, every cart was exactly the same and you didn’t have to figure out how it was organized, and then we stopped wasting time looking for things,” Boone says.
Then, instead of having phlebotomists bring stacks of labels to their floor and send large batches of specimens back down to the laboratory all at once, the hospital set up a pneumatic tube station through which labels could be sent to the phlebotomists as they needed them. Then, they could take blood from a patient, label the specimen, and “tube it” back down to the laboratory.
This saved the laboratory a “considerable amount of time, and it helped us level-load the work coming into our laboratory,” Boone says. “Instead of getting big batches brought in, we found that by tubing [a specimen] down as it was drawn, we had smaller amounts coming into our lab, and it helped the processors and the techs who were testing the specimens to receive them in a slower fashion.”
It also helped eliminate some of the patient-misidentification risks that were involved with taking stacks of labels up to a floor. “Before, there was always the fear of getting the wrong labels going into a room and drawing a sample incorrectly,” Boone says. “So when we changed the process to eliminate their handling all labels in their hands at one time, it improved that process.”
They also found that this new system was faster. “We did studies and found that when a phlebotomist is taking one label and going to the patient room, drawing a sample, bringing it back to the pneumatic tube station, sending it down, and then taking a label and drawing another one, it is actually just as fast or faster than to do it with a stack of labels on your tray,” Boone explains, adding that staff had to be convinced of this in the beginning. “It was hard for everyone to realize at first that it was actually much faster and much safer from a patient standpoint when you went into a room for an encounter with just one set of labels with you.”
One Needed Step
But once the phlebotomy team was convinced that the new processes were working more efficiently, the laboratory staff realized all of their problems were not yet resolved. The phlebotomy dispatcher in the laboratory still had to spend a great deal of time every evening hand-sorting stacks of labels for the big morning pickup the following day. “They would start around 6 pm or 7 pm and pull hundreds of labels that had to be sorted and divided up, and each person had to have an equal share, and it took hours,” says Margo Eudy, MT (ASCP), in-house phlebotomy manager for the laboratory. “We knew that was one thing we had to improve, that this was not an efficient use of a phlebotomy supervisor’s time. So we were looking for something to improve that process.”
Boone agrees that the lab was ready for the next step. “We had organized our processes to the point that we had eliminated a lot of the nonvalue-added activities, and we had things pretty standardized. But we were still spending a lot of time with the labels, and somebody was still always having to call and find the phlebotomist to tell him or her they had a STAT,” she says. “We always had to beep and page the phlebotomist, who couldn’t see what the orders were.”
With the new system at the Medical Center Laboratory, a portable label printer can print labels in the patient’s room and the patient can watch as the phlebotomist labels the tubes.
At the time, they were already using collection tubes from BD Diagnostics, a manufacturer based in Franklin Lakes, NJ. Therefore, Boone says the company was a “natural place to start” in their search for a better labeling system. “We looked at the BD.id product, and it offered us the identification validation we wanted at the bedside,” she says. “It also meets the [Joint Commission on Accreditation of Healthcare Organizations, or JCAHO] safety goal initiative for patient identification.”
The West Tennessee Healthcare system was in the process of looking at ways to use bar codes with patients for better identification (ID), so the BD.id product, Boone says, fit right in with their plans. “We began using bar codes in phlebotomy, and soon they will be used in other areas within the organization,” she explains.
This was a good way for the laboratory to improve, says Beth DiLauri, senior marketing manager for BD.id Systems. “They had done a fair amount of work eliminating waste and opportunities for error in their processes and wanted to take it to the next step by applying automation,” she says.
The system includes a small, handheld device, a patient data terminal (PDT) that resembles a Blackberry, and a portable label printer. The device reads the patient’s bar code, then gives the phlebotomist the standard order of draw. “It tells you what orders that patient has in our laboratory computer system, and then it will list in what order [the samples] must be drawn,” Boone explains. Once the venipuncture is completed, the machine will print the labels in the room, and the patient can watch as the phlebotomist labels the tubes.
“Then, the phlebotomist takes the handheld device back to the pneumatic tube station and docks the PDT, which will transmit that collection through the cabling in the interface back to our lab,” Boone says. “It will put it in the tube system, and then the person receives it on the other end, and begins the testing. The phlebotomist picks up the PDT, and it’s programmed for all the spots in the hospital, and they can see their whole floor right there—all the patients who have orders—and see what those orders are.”
This way, if a nurse puts a new order into the laboratory’s computer system, the phlebotomist out on a floor can see it. “They don’t have to wait to be beeped, called, and paged by the supervisor in the lab to be told they have an order—they can see it,” Boone says. “So they’re able to manipulate their workload a lot better. They can check it and say, ‘Oh, they just added a STAT on Mr Brown on this floor; I can get it before I leave.’ It helps you do real-time collection in a much more organized fashion.”
What the system is really designed to do, DiLauri says, is streamline the specimen-collection process and ensure that both the patient ID and the specimen ID are correct, “because the tube, once the blood is drawn, represents the patient.”
The first step is getting the patient ID right, she explains. “And the second step is associating that specimen with the patient right at the bedside and immediately making sure that’s the right specimen for that patient in the right containers,” she says. “Labeling that specimen properly with the patient ID and all the information needed right at the patient’s bedside is really the crux of what we’re trying to do.”
She also notes that this fits with JCAHO’s national patient-safety goals for 2006, which have an increased focus on specimen ID at the bedside. A phrase has been added to the list of goals for patient ID that stipulates there should be not only two identifiers for the patient when drawing blood, but also two identifiers for the specimen.
“There’s recognition of the high amount of risk in getting that labeling piece correct and the opportunity for error if you have multiple patients, multiple labels, and multiple containers,” she says.
According to DiLauri, the system also eliminates the need for the laboratory staff to handle huge batches of labels at once—which reduces the chance for errors.
Without the system, phlebotomist dispatchers in laboratories like Boone’s usually “run the print of all ordered specimens in the overnight shift, and someone will sort those labels and they get sent out for collection,” she says, adding that with this system, “you have one patient, you draw the blood for that patient, and you have no labels until you ID the patient and the container, further reducing the opportunity for error.”
Labeling mistakes can often cause erroneous results, leading to the need for additional samples to be taken. “So we’re eliminating that need for delay in treatment and the staff redrawing when it could have been avoided,” she says. “Nobody wants to be the person who has to go back and draw blood again.”
Seeing the Benefits
The Medical Center Laboratory at Jackson-Madison County Hospital only rolled out the system in September, but the staff there has already seen great results. For one thing, that dispatcher in the lab no longer has to pull all of the labels and “do all of that resorting by hand for the big morning pickup,” Boone says. “Now, phlebotomists come in, get the label printers, and head off to their assigned floors. When they get there, the PDT is there at the pneumatic tube station and they proceed to pick up what’s on that floor. When something is timed and comes overdue, it turns a different color, so they can recognize that they need to get it, and they can get it in that window of opportunity before they leave the floor.”
Eudy has seen these kinds of improvements firsthand. “It really has helped,” she says. “It has freed the supervisors up to do more of the training and not be tied to the computer terminal and to the tube system, pulling out labels.”
She adds that many times now, the dispatcher will call or page phlebotomists to tell them they have a STAT order, but they have seen this and have already collected the specimen.
Boone says it has also demonstrated the benefits of using a bar-code system, something that could be used in many other ways within the hospital, such as for glucose testing and pharmacy processes, and in the maternity ward. “This is where things are headed,” she says. “I can see this type of technology rolling out across the hospital in various forms.”
The system also means the phlebotomists will no longer tax the pneumatic tube system by sending labels back and forth, she adds.
And as for the patients? Boone says one joked with a phlebotomist that he felt like a can of peas at a grocery store with the bar code, but she also says they appreciate seeing their blood sample being labeled right in front of them, so they know it is correct.
DiLauri says the system, which was originally released as a wired version in 2003, now has a wireless platform—but that it can be used either way. The product has received great customer feedback, she says, especially for its ease of use and high degree of accuracy.
Boone explains that one of the biggest benefits has been in helping phlebotomists not only be more accurate and efficient, but also to simply feel better about their jobs. This has been especially apparent with on-the-job phlebotomy training, which has clearly helped people learn faster. “This instrument makes them so much more confident,” Boone says. “They can better organize their work and do it on time, so they can concentrate on the art and the skill of the venipuncture.”
Sarah Schmelling is a contributing writer for Clinical Lab Products.
