A Sharper Phlebotomy Service

A Sharper Phlebotomy Service Preparing for the future Submission for the 2014 Canterbury DHB Quality Improvement and Innovation Awards Megan Harris, Karen Heatley, Linda Boyce, Jaine Duncan Canterbury Health Laboratories Canterbury District Health Board

Table of Contents Project Information Sheet... 1 Abstract... 2 Introduction and Background... 2 Planning and Implementation... 3 Results and Findings... 7 Conclusions and Future Direction... 10

Project Information Sheet Project title A Sharper Phlebotomy Service Name and address of service/department Patient Services, Canterbury Health Laboratories Cnr Hagley Ave & Tuam St Contact Person Name Job Title Email Linda Boyce Phlebotomist Linda.boyce@cdhb.health.nz Address: Canterbury Health Laboratories, Cnr Hagley Ave & Tuam St Telephone: 378 6647 Word Count (limit 3000) 2700 (+ tables and diagrams) 1

Abstract The inability to flex staff to meet demand was the motivation for this Lean based project within the phlebotomy service. Canterbury Health Laboratories operates both the ward based and outpatient based phlebotomy service across all CDHB hospital sites within Christchurch. A dedicated project team was seconded to run a targeted short timeframe project with the goal of improving the visibility of phlebotomy staff while on the wards and obtaining prior knowledge of workload demand. The introduction of a coordinator to determine prior workload and liaise with phlebotomy staff while on ward rounds has enabled staff to be flexed across the service to meet demand. This has resulted in a dramatic reduction in time spent searching wards for work or colleagues. The coordinator is also available to assist with patients as they arrive in the Blood Test Centre thereby improving our patient service. The use of smart phones has improved communication and provided access to current information on testing and sample collection requirements. Standard work has reduced variation and the incorporation of hand hygiene moments has ensured compliance with infection control requirements. Increasing the frequency at which blood samples are transported back to the laboratory for testing has reduced the time from sample bleed until availability of result. As the ability for proactive management of staff has increased there has been an improvement in the team dynamic and a significant increase in staff satisfaction. A system of audit and review has been established to ensure on-going compliance with accreditation standards and project initiatives. Understanding workload demand and staff capacity is the key in being able to respond to the daily challenges of managing a phlebotomy service. The Lean principles learned have provided a foundation for continuous improvement in preparation for any CDHB initiatives where the phlebotomy team will play a role in improving the patient journey. Introduction and Background Canterbury Health Laboratories (CHL) operates a ward round based phlebotomy service across the Christchurch Hospital (CPH) and Christchurch Women s campus as well as Burwood and the Princess Margaret Hospitals (TPMH). Utilising the services of 35 registered phlebotomists, the service cover is Monday to Friday with reduced weekend ward rounds to all sites. This is a routine service although priority is given to urgent requests, acute wards and fasting bloods where possible. The bulk of the daily ward round workload (70 80%) is completed by 10:00am. CHL also operates five outpatient Blood Test Centres (BTC) in Christchurch servicing both out-patient clinics and the community: three are located within the Christchurch Hospital and Christchurch Women s campus and one each at the other two hospitals. The centres are open between 0730-1700 Monday to Friday, depending on the location and day, with the facility situated within CHL also providing a Saturday morning service. Phlebotomy ward rounds have always been approached systematically with phlebotomists going to a designated ward block and individually working through wards eventually intersecting with colleagues. Phlebotomists dealt with the demand on an ad hoc basis with no knowledge of demand on other wards or issues that colleagues may be facing across the hospital. Each ward would be checked for blood requests resulting in a significant amount of walking often unnecessarily if no blood requests were waiting or if a colleague had already completed that ward. When wards were completed phlebotomists would endeavour to find colleagues to offer help with any remaining blood requests. During this time there was no ability to know the level of demand at the BTC or to relocate staff more appropriately. As capacity issues surfaced, particularly throughout the morning, this limited knowledge around workload and staff location resulted in a constant state of reactive management. The need for pro-active staff management around capacity and demand and a more even distribution of work across the phlebotomy team was the catalyst for change which resulted in this Lean based project. It was 2

also an opportunity to address the requirement to meet international standards for access to a fully updated test data base containing testing and sample collection requirements.. Project team The project team incorporated a mix of skills in terms of project experience and phlebotomy knowledge. CHL Process Improvement Project Facilitator Project Lead Phlebotomy supervisor Experienced phlebotomist Senior medical laboratory scientist Operating theatre aid with previous Lean experience Planning and Implementation The project was structured using the DMAIC framework and run over a six week period. Define Assessment of the current state to identify improvement opportunities. Data was collected on demand, frequency of transporting samples to the laboratory and time spent checking wards for blood requests or locating colleagues. Phlebotomists were observed both on ward rounds and in the BTC. Observations focused on work practices and the ability to communicate with colleagues. Phlebotomy staff were also asked to complete a staff satisfaction survey. Charge nurse managers were contacted in regard to their view of the phlebotomy service with other general medicine and general surgery staff spoken to informally. Discussions with key laboratory staff provided feedback on their concerns or issues relating to phlebotomy. A presentation introducing Lean concepts was given to the phlebotomy team with an opportunity for discussion and feedback. Key Findings Poor visibility of staff out on the wards No knowledge of workload across the hospital Limited ability to communicate with staff while on ward rounds Batching of samples to send back to the laboratory Phlebotomists using outdated hardcopies of the test data base Project Goals Improve visibility of phlebotomy staff while out on ward rounds Improve prior knowledge of work demand on wards Reduce the time from sample bleed to arrival in the laboratory Reduce variation in work processes Improve staff satisfaction Although the phlebotomy service covers three sites it was decided to focus primarily on CPH with a planned roll out to TPMH phlebotomy service. A smaller project at Burwood hospital in preparation for the development of the Burwood site and relocation of Older Persons Health Specialist Services (OPHSS) was planned for the future. A steering committee consisting of key management staff was set up to oversee progress of the project, remove roadblocks if required and make strategic decisions when necessary. 3

Final sign off was obtained from the steering committee after presentation of assessment findings together with a project recommendation followed by a detailed charter stating project goals. Measure and Analyse Detailed data collected to identify root causes. Phlebotomists were followed and data collected on the time spent searching for work or colleagues and the distanced travelled while on the wards. Detailed data was collected on the length of time from sample bleed until transportation back to the laboratory using the pneumatic tube system (Lamson). Observations were recorded on the variation in work process and hand hygiene moments. Improve Examination of root causes to determine improvement initiatives. Initiatives were trialled, refined from staff feedback and implemented in conjunction with training, education and support from the project team. Initiatives implemented: Using a coordinator based at the BTC to monitor demand both on the wards and within the BTC and flex staff as required. Key tasks o Phone wards prior to 7am ward round to establish demand and assign staff accordingly. o Monitor progress of ward round completion displaying the information on a central whiteboard. o Greet patients and do a preliminary check of patient request forms; clarifying details, printing request forms of regular patients from the electronic system and checking for any special testing requirements. Provide pottles or swabs where needed. Providing a smart phone for each phlebotomist to use on ward rounds to communicate with and feedback to the coordinator. The smart phone can also be used to access test manager, an up to date electronic version of the test data base containing testing and sample collection requirements. Sending samples back to the laboratory every 30 minutes via the Lamson system. Phlebotomists returning to the laboratory from Hagley Outpatients or Christchurch Women s Outpatients bring any waiting blood samples rather than leaving them for the next scheduled orderly pickup. Introduction of standard work for the phlebotomy procedure to reduce variation and clarify the appropriate points where hand hygiene is required. Standardisation of phlebotomy trolleys. 5s of the stock rooms. As initiatives were trialled and implemented opportunities for further staff education were identified. Key areas included: Understanding the five points of hand hygiene when dealing with patients to reinforce and standardise against infection control requirements. Using the Lamson system efficiently without affecting sample integrity. Importance and benefits of standard work with specific training around the introduction of the phlebotomy standard work. Control Implementation of systems to embed and sustain initiatives. Detailed plans were made for on-going sustainability and future improvement opportunities. Post project data was collected and a repeat staff satisfaction survey performed. 4

Multiple forms of feedback and communication were necessary to keep the phlebotomy team, many of whom work part time hours, up to date with the initiatives and planned next steps. A project board situated within the BTC was updated frequently with key project milestones and provided an area for staff feedback and ideas. Several group sessions were held to feedback to staff and give them the opportunity to ask questions. Focus groups consisting of both project team members and other key phlebotomy staff were used to develop and trial standard work and define the coordinator role. Weekly written reports were circulated to the steering committee members outlining major accomplishments and next steps. Fortnightly steering committee meetings included progress updates and provided an opportunity to discuss any significant road blocks and review progress against the project timeframe. Risks were assessed during each stage of the project; new protocols were reviewed against accreditation standards and infection control requirements, targeted training ensured competency and on-going communication and feedback highlighted issues allowing a change in initiative where necessary. 5

PROJECT TIMELINE Assessment feedback Steering Committee Phlebotomy staff Project update Steering Committee Phlebotomy staff Project update Steering Committee Stakeholders Project summary Steering Committee Phlebotomy staff Key stakeholder engagement Data collection Lean training Data collection Trial initiatives Implementation of initiatives Post data collection February 2013 Assessment Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 April 2013 Staff satisfaction survey Development of standard work Trolley standardisation Stock room 5S Staff training and support Convert to electronic request form storage Staff satisfaction survey 5S BTC Define Measure & Analyse Improve Control 6

Results and Findings The improved visibility of workload and location of staff out on the wards together with the ability to communicate with and coordinate the staff has resulted in proactive staff management. This has seen an improvement in the team dynamic and an increased level of support within the team. Introduction of the coordinator to gauge demand prior to the 7am ward round, monitor progress of ward round completion, staff location and areas of increased workload gives the ability to flex staff across the hospital and within the BTC. Smart phones have provided both a means of communication with the coordinator and access via the internet to test manager giving up to date information on test requirements. Overall the improved communication and knowledge around staff location has reduced the the time spent searching wards for work or colleagues and the distance travelled by the phlebotomists. (Table 1) Having the coordinator available to greet patients at the BTC provides a more patient centric focus. Request forms are printed ready for the phlebotomist thereby reducing patient wait times and those patients requiring specialist testing can be identified and have procedures started earlier. Increasing the frequency at which blood samples are transported back to the laboratory via the Lamson system has reduced batching thereby reducing the time from sample bleed to arrival in the laboratory. (Table 1) This improves the overall turnaround time of the blood test result from blood draw until result availability for the clinician. Table 1 Time Spent Searching and Distanced Travelled Time from Sample Bleed to Arrival in Laboratory Measure Baseline Post Project Improvement Average time searching for work/colleagues during the 7am ward round 25 minutes 5 minutes 80% reduction Average distance travelled by staff during the 7am ward round 2600 steps 319 steps 88% reduction Average time from sample bleed to arrival in laboratory 3 rd floor wards (CPH) 70 minutes 32 minutes 54% reduction Hagley Out- Patients 135 minutes 45 minutes 67% reduction Christchurch Women s Out-Patients 120 minutes 35 minutes 71% reduction Blood Test Centre at CHL 50 minutes 26 minutes 48% reduction 7

The introduction of a standard work protocol for the phlebotomy procedure (Figure 1) including clarification of the required hand hygiene has reduced the variation and established structure around the process. Working with the infection control team provided the phlebotomists with a better understanding of the patient zones and the requirement for hand hygiene at different times within a patient related procedure. Correct hand hygiene procedures when dealing with patients decreases the risk of hospital acquired infection. Standardisation of phlebotomy trolleys and the 5s of the stock rooms resulted in less time spent restocking trolleys prior to ward rounds. Figure 1 Standard Work for Phlebotomy Procedure Hand Hygiene Before entering patient zone Hand Hygiene Immediately before procedure Hand Hygiene Reduce body fluid exposure risk Patient ID Verbal & wristband check. Confirm on form Prepare equipment Prepare patient Tourniquet on Select vein Swab skin Draw blood Apply pressure Label tubes Write/stamp on form Bloods/form to bag Apply dressing Hand Hygiene Before leaving patient zone A significant improvement in staff satisfaction post project was seen. (Table 2) Additional project benefits Obtaining patient room numbers from a patient ward list prior to arrival on the wards has eliminated the need to access the ward board during busy times. By highlighting patients that have been bled and returning the list to the blood test box on the ward, there is a clear visual indicator to other phlebotomists and medical staff if a patient has already been bled. This has resulted in a reduction in the number of duplicate forms on the same patient. Transferring original request forms of outpatients who have regular visits to the BTC to an electronic format for printing when required, has improved efficiency and reduced the requirement for multiple filing cabinets. Installation of a fixed ipad in the BTC has improved the accessibility of the test manager data base. Improving the layout of the patient rooms within the BTC has reduced the amount of walking to locate equipment and supplies and removed unnecessary clutter. 8

Table 2 Staff Satisfaction Survey Pre Implementation Post Implementation 1. I am satisfied with the level of service (quality, timeliness, accuracy) we provide to our customers (patients, CDHB staff, GP s) 45% 11% 33% 11% strongly disagree disagree neutral agree strongly agree 13% 75% 12% strongly disagree disagree neutral agree strongly agree 2. We have systems in place to flex staff as required during our working day 56% 33% 11% strongly disagree disagree neutral agree strongly agree 38% 62% strongly disagree disagree neutral agree strongly agree 3. I feel relaxed and in control of my working day 11% 11% strongly disagree 12% strongly disagree 22% disagree neutral disagree neutral 56% agree strongly agree 88% agree strongly agree 9

Conclusions and Future Direction The ability to communicate with staff and knowledge of demand versus capacity is the key to enabling staff to be flexed as required. Staff responded well to a process improvement initiative within their area and became empowered with the ability to improve their workflow and environment. Seconding the area supervisor to the project team allowed her the opportunity to see the issues and understand the root causes. This ensured ownership of the project and an in-depth understanding of Lean principles and the key concepts of improving workflow by reducing waste. A detailed follow-up list of action points around procedural reviews, roll out initiatives and audits was included in the post project handover to the area supervisor. Audits of standard work have been on-going since the completion of the project with the phlebotomist from the project team taking a lead role in the auditing. Staff are audited a minimum of twice yearly against an audit check sheet to determine compliance with standard work protocols and accreditation requirements. Spot audits of the phlebotomy trolleys are also performed. Immediately post project the standard work protocol for the phlebotomy procedure and standardised phlebotomy trolley were rolled out to both TPMH and Burwood hospital. A smaller project at Burwood hospital reviewing the phlebotomy service is now complete and was used as an opportunity to further develop the phlebotomist used on the original project team. Key lessons learned: For some staff the introduction of electronic devices is challenging and extra training needs to be scheduled into the programme. Introduction of multiple initiatives over a short time frame risks poor sustainment as staff struggle to adapt to the changes. Staff need to understand the importance of the entire patient journey and not just their task within it. For the phlebotomy team this is about ensuring that samples are regularly sent back to the laboratory. Staff feel more in control when prior knowledge of workload is available and they know that backup is available. Importance of communication and feedback throughout a process improvement project cannot be over stated. On-going monitoring of staff is essential to maintain compliance of initiatives. Summary presentations were given to the steering committee, phlebotomy staff, CHL management team and the Ashburton Hospital laboratory, providing visibility of the project successes and sharing key achievements. A written project summary recorded in detail the assessment findings, data collected, initiatives trialled and implemented, results achieved, procedure changes, role definitions and the detailed follow-up list. The phlebotomy team are now well placed to encompass the roll out of electronic order entry which will provide a real-time view of demand thereby further improving their ability to flex staff. Across all CHL activity is a desire to reduce waste and introduce standard work practice. This targeted short timeframe project successfully showcases the benefits of using a dedicated team to provide the impetus for change using Lean methodology to achieve these goals. The initiatives of this project and the Lean principles learned are the basis for continuous improvement within the phlebotomy service providing the foundation to respond to the needs of the CDHB priority work streams. The ability of the phlebotomy team to have patients bled and samples delivered to the laboratory in a timely manner will continue to play a critical role in the patient journey, particularly in terms of patient discharge. The Frailty Programme has highlighted the importance of timely discharge and the clinical criteria for discharge (CCD) of which blood results play a significant role. 10