Chapter 1

Phlebotomy Practice and Quality Assessment

CHAPTER OBJECTIVES

1. Define phlebotomy and identify health professionals who perform phlebotomy

procedures.

2. Identify the importance of phlebotomy procedures to the overall care of the patient.

3. List professional competencies for phlebotomists and key elements of a performance

assessment.

4. List members of a health care team who interact with phlebotomists.

5. Describe the roles of clinical laboratory personnel and common laboratory

departments/sections.

6. Describe health care settings in which phlebotomy services are routinely performed.

7. Explain components of professionalism and desired character traits for phlebotomists.

8. Describe coping skills that are used for stress in the workplace.

9. List the basic tools used in quality improvement activities and give examples of how a

phlebotomist can participate in quality improvement activities.

10. Define the difference between quality improvement and quality control.

KEY TERMS

acute care

aliquot

ambulatory care

American Society for Clinical Laboratory Science (ASCLS)

American Society for Clinical Pathology (ASCP)

anatomic pathology

Centers for Medicare & Medicaid Services (CMS)

clinical decisions

Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988)

clinical pathology

competency statement

continuing education (CE)

continuous quality improvement (CQI)

examination (analytical phase)

Food and Drug Administration (FDA)

home health care

inpatients

International Organization for Standardization (ISO)

long-term care

National Phlebotomy Association (NPA)

nosocomial infections

personal protective equipment (PPE)

phlebotomist

phlebotomy

physician’s office laboratories (POLs)

point-of-care (POC)

postexamination (postanalytical phase)

preexamination process (preanalytic phase)

professionalism

quality

quality control (QC)

quality improvement

Six Sigma

stakeholders

standards of practice

LECTURE OUTLINE

I. Phlebotomy Practice and Definition

A. Definition of Phlebotomy

1. Derived from the Greek words, phlebo, which relates

to veins, and tomy, which relates to cutting.

2. Definition can be summarized as the incision of a vein

for blood letting.

3. Synonymous words are venesection or venisection.

B. How Are Laboratory Analyses Used?

1. Diagnostic: to figure out what is wrong with the

patient.

2. Therapeutic: to develop the appropriate therapy or

treatment of the medical condition.

3. Monitoring: to make sure the therapy or treatment is

working to alleviate the disease or illness.

C. Job Sites for Phlebotomists (Box 1–1)

1. Hospitals in the United States (Box 1–2)

a. There are approximately 6,000 hospitals in the

United States.

i. Mission (patient care, education, research).

ii. Number of beds.

iii. Ownership (public or nonprofit,

governmental, for-profit or proprietary).

iv. Length of stay (short-term [e.g., less than 30

days]; long-term [e.g., greater than 30 days]).

v. Type of care provided (acute care hospitals;

and specialty care hospitals, such as birthing

centers, cancer centers, psychiatric hospitals,

pediatric hospitals, and rehabilitation

hospitals).

vi. Location (urban or rural).

vii. Relationship to other health facilities

(integrated hospital systems, religious

multihospital systems, independent

hospitals).

b. Medical, Surgical, and Ancillary Departments

(Table 1–1)

D. The Health Care Team (Box 1–3)

II. The Clinical Laboratory & Specimen Collection Services

(Figure 1-1)

A. Anatomical versus Clinical Pathology/Laboratory Medicine

1. In the clinical pathology area, blood and other types of

body fluids and tissues are analyzed (e.g., urine,

cerebrospinal fluid [CSF], sputum, gastric secretions,

synovial fluid).

2. In the anatomic pathology area, autopsies are

performed, histologic and cytologic procedures are

utilized for tissue and fluid specimens, and surgical

biopsy tissues are analyzed.

B. The Clinical Laboratory Workflow Pathway (Figure 1–2)

1. Preexamination (preanalytical phase)

2. Examination (analytical phase)

3. Postexamination (postanalytical phase)

C. Regulatory Agencies

1. FDA, CMS

2. CLIA (Box 1–4)

a. CLIA categorizes laboratory tests according to the

level of complexity of the testing procedure and

the risk involved for the patient if errors are made

in performing or interpreting the test.

b. Waived tests are the easiest to perform, the least

susceptible to error, and the least risky to patients.

i. Urinalysis

ii. Urine pregnancy tests

iii. Blood glucose screening tests

c. Tests of moderate complexity are simple to

perform but may involve more risk to the patient if

results are inaccurate.

i. White and red blood cell counts

ii. Hemoglobin

iii. Hematocrit

d. Tests of high complexity are complex to perform

and may allow for reasonable risk of harm to the

patient if results are inaccurate.

i. Molecular analyses

ii. Bone marrow evaluations

iii. Immunoassays

3. The Joint Commission, AABB

D. Clinical Laboratory Departments (Figure 1–1)

1. Administrative office

2. Laboratory supervisory/management personnel

E. Clinical Laboratory Personnel (Box 1–5)

III. Competencies, Certification, and Professionalism for

Phlebotomists

A. Professional Competencies and Certification

1. A high school diploma or its equivalent is most often

required to enter a phlebotomy training program in

hospitals, community colleges, or technical schools.

2. The length of training varies from a few weeks to

months, depending on the location, size of the facility,

and/or the complexity of patients being served.

3. Employers often require phlebotomy certification,

which is accomplished by passing a national

certification examination. (Tables 1–2 and 1–3)

B. Fundamental Duties of Phlebotomists (Box 1–6, Table 1–2)

C. Professionalism (Figure 1–3, Tables 1–2 and 1–3)

1. Respect

2. Service

3. Support

4. Growth

5. Professional Organizations for Phlebotomists (Table

1–3)

D. Ethical Standards and Character Traits

1. Ethical standards

a. Do no harm to anyone intentionally.

b. Perform according to sound technical ability and

good judgment.

c. Respect the patients’ rights (confidentiality,

privacy, the right to know about their treatment,

and the right to refuse treatment).

2. Character traits

a. Sincerity and compassion

b. Emotional stability and maturity

c. Accountability for doing things right

d. Dedication to high standards

e. Respect for patients’ dignity, confidentiality, and

the right to know

f. Propensity for cleanliness

g. Pride, satisfaction, and self-fulfillment in the job

h. Working with team members

i. Take pleasure in communicating with patients

E. Appearance, Grooming, and Physical Fitness (Figure 1–4)

1. Posture

a. Erect posture conveys confidence and pride in job

performance.

b. Good posture minimizes back and neck strain.

2. Grooming and personal hygiene

a. Overall tidy appearance communicates a

commitment to cleanliness and infection control

and instills confidence.

b. Employers are legally required to provide personal

protective equipment (PPE).

3. Sample Dress Code Policy (Table 1–9)

F. Stress Management (Box 1–10)

IV. Quality Improvement and Assessment

A. Perceptions of Quality

1. Quality: the degree to which a set of inherent

characteristics fulfills requirements

2. Two categories of quality in health care

a. Scientific/technical

b. Nontechnical/interpersonal

3. Three concepts of quality in health care

a. Efficacy

b. Appropriateness

c. Caring functions

4. Stakeholders (Box 1–11)

5. CLSI’s Quality System Essentials (Box 1–13)

6. Globalization and Standardization (Box 1–12)

B. Quality Improvement for Phlebotomy Services focuses on

preexamination/preanalytical issues.

1. The health care worker’s technique

2. Patient identification procedures

3. Waiting times

4. Complications

5. Recollection/repeat venipuncture rates

6. Multiple sticks on the same patient

7. Duplicate test orders for the same patient

C. Quality Plan for Phlebotomy Services (Table 1–4)

1. Structure, where services are provided

2. Processes, what is done to the patient

3. Outcomes, what is accomplished for the patient

4. Customer satisfaction, how satisfied are the

stakeholders

D. Tools for Quality Performance Assessment

1. Flowcharts (Figure 1–5)

2. Pareto charts (Figure 1–6)

3. Cause-and-effect (Ishikawa) diagrams (Figure 1–7)

4. Plan-Do-Check-Act cycle (PDCA)

5. Line graphs, histograms, scatter diagrams

6. Brainstorming (Box 1–14)

E. Quality Throughout the Laboratory Testing Cycle (Figure

1–8; Box 1–15)

F. Quality Control—A Key Component of Laboratory Quality

Assessment

1. QC measures

a. Are functions of everyday practice in clinical

laboratories

b. Set parameters for making sure test results reflect

what they are supposed to measure

c. Test results can be reproduced

d. Set performance standards and acceptable ranges

G. Future Trends in Phlebotomy Practice

1. Standardization and globalization

2. Electronic medical records

3. Smaller, faster laboratory testing

4. Direct access testing (DAT) or direct to customer

(DTC)

5. Education/certification

INSTRUCTIONAL MATERIALS

From Phlebotomy Handbook (8th ed.), provide student copies of:

Appendix 2: Finding a Job

Appendix 15: Competency Assessment Tracking Sheet

Dress code policy (you may use the one in Table 1–5 if needed)

From www.pearsonhighered.com/garza

Assessment questions

Labeling exercise

Freeze Frame Video exercise

Case study

Quest for a Million

Strikeout

Crossword puzzle

Word search

Cognition

Racing Pulse

Vocabulary 911

Teaching Strategies

1. Take the students on a tour of a health care facility and introduce them to members

of the health care team in various departments. If possible hand out the

organizational charts for the organization and/or the clinical laboratory. After the

tour:

a. Ask students to complete the Phlebotomy Self-assessment (Box 1–8). Encourage

students to speak with the instructor or career counselor about career goals

and/or any doubts they might have regarding their decision to pursue

phlebotomy as a career.

b. Have each student write a brief description and his or her impressions of at least

four departments in the health care facility.

2. Allow students to make a list of at least five health care professionals who may be

involved in the specimen collection process. The instructor should facilitate the

discussion by asking students to describe the expectations about each one’s roles

and responsibilities on the health care team. Have students discuss how other

responsibilities help or hinder the specimen collection process.

3. To reinforce professional ethics and behavior, students should work in teams or

groups. The following exercise can be used as a contest or simple class exercise.

a. Students should work in groups of three to five. Their assignment is to write a

list of five to ten essential “dos” and “don’ts” of professional behavior for

phlebotomists.

b. The instructor may judge the lists based on consideration of patient concerns,

ethical considerations, and/or professional competencies. The judging criteria

should be mentioned to the groups before they begin writing their lists.

4. Have students discuss their own phlebotomy experiences in small groups. Assign

one of them to be the scribe at the blackboard and have the scribe list positive and

negative factors in the experiences shared by the groups. Summarize by indicating

that through their upcoming educational and work experiences they will be able to

control some of the factors that they mentioned.

5. Ask students to check out websites and identify the roles of various professional

organizations and certifying agencies. They may start with the websites listed in

Table 1–3: Professional Organizations for Phlebotomists

6. To prepare students for phlebotomy training and evaluation, the instructor should

review the “ASCP Competency Statements for Phlebotomy Technicians” listed in

Table 1–2 of Phlebotomy Handbook, 8th edition. Ask local hospitals for copies of

job descriptions for health care workers involved in specimen collection.

The role of certifying and state-specific licensing exams should be covered, and

many options for professional advancement should be mentioned. Even if the

health care worker does not plan to take a certifying examination specifically for

phlebotomists, he or she will benefit from knowing what employers’ job

expectations are and how the employees will be evaluated.

Role Playing

1. Assign each student a type of health care facility (see following examples).

Encourage them to visit or tour the facility if possible, and ask them to write a brief

description of the facility, including classification—primary, secondary, or tertiary

care; specialty care; and other pertinent information. If the facilities are not easily

available, ask them to do the research online using organizations’ websites in their

state or region.

List of Health Care Facilities

• Long-term rehabilitation center

• Psychiatric hospital

• Geriatric health care facility

• Blood donation center

• Health maintenance organization (HMO)

• Community health center

• Surgicenter

• Public health department

• School-based clinic

• Home health care agency

2. Ask the students to list at least four laboratory procedures that they are familiar

with and are done in a clinical laboratory. They should describe how these tests

were likely to be used by the health professional (e.g., diagnosis, therapy,

monitoring).

3. To assist students in finding a job, they may begin preparing a résumé. Examples of

job application forms, résumés, and cover letters to employers should be circulated

to the students so they may view different formats and styles. Students are usually

very motivated to develop their own résumés, and it is never too early to begin this

process. If a student already has a résumé, he or she should update it. Use the case

study below as a classroom exercise to open the discussion about the importance of

a resume.

4. To prepare students for a job interview, the following issues should be discussed in

class or among groups.

• Qualities that employers value most in their employees.

• “Dos” and “don’ts” in an interview.

• Qualities important for job advancement.

• Commonly asked questions during the interview.

• Questions that the applicant might ask the employer.

• Importance of a follow-up letter after the interview.

• Role-playing an interview scenario can be helpful and fun for students.

• Tips about webcam interviewing and implications of personal information online

(eg., MySpace, YouTube, etc.)

5. To introduce the topic of ethical behavior, ask students to imagine a situation where

there might be an ethical decision for a phlebotomist. To set the stage, ask them to

consider some of the current medical programs they have seen on television and

think about the following:

• What can go wrong in any health care settings?

• Why is it difficult for people to admit their mistakes?

• What are some of the basic rights of any patient in a health care setting?

• What is an example of an unethical behavior by a patient?

• What do you expect that a phlebotomist’s rights include?

Keep in mind that some of these issues will be discussed in later chapters, but it is a

good idea to get the students thinking about these issues early in the curriculum.

Case Study

Cathy was interested in getting a part-time job during the last year of her college

education. She had previous experience as a phlebotomist but was in a different city

from where she had worked previously and from where she had grown up. She did not

know anyone who worked at the local hospital or clinics in the area. She did not know

where to begin her job search.

1. What could Cathy do to begin her search?

2. What should she include on her resume?

Answers

1. Cathy has several options on how to begin and should be as resourceful as possible

if she is serious about getting a job. Refer to Appendix 2 in the textbook for more

details, but here are a few tips to begin a job search:

• Monitor local newspapers and laboratory professional journals for job postings,

both electronically and in print.

• Identify local places that might hire phlebotomists (hospitals, clinics, health

department, etc)

• Ask any health professionals in the area about the reputation of various

organizations.

• Ask for advice from health care professors/instructors about possible job

opportunities.

2. Basically, a résumé should include the following components:

• Legal name and preferred contact information (address and phone/fax number(s);

e-mail address).

• Position desired and job or career objectives.

• Qualifications and special abilities or skills.

• Educational background, usually beginning with the most current courses,

certificate, or degree (it can be noted that transcripts will be furnished on

request).

• Employment experience, usually beginning with the most recent. This section

should include dates of employment, employer’s name, the position held, and a

brief description of responsibilities.

• Certifications, awards, honors, memberships and/or affiliations in professional

organizations.

• Community service involvement, optional.

• Outside interests, optional.

Case Study

Suppose a coworker asks you to sign out/clock out for him at his regularly scheduled

time at the end of his shift. He says he needs to leave early but doesn’t have any

vacation time left and states that this is only a small favor for one time.

1. What would you do?

2. What should you do?

Answers

1. Hopefully, you would not do as he asked because it would be falsifying records that

belong to your employer.

2. In addition to refusing the request, you should discuss the inappropriate situation

with the employee and report it to a supervisor. If the employee is willing to falsify

his own time sheet, there could be other documents that he has or is tempted to

falsify as well, including patient results, etc. To protect patients, the other

employee, your employer, and yourself, it behooves you to report any possibility of

wrongdoing.

Competency Checklist: Basics of Phlebotomy Practice and the Clinical Laboratory

(1) Completed   (2) Needs to improve

_______ 1. List at least five service areas/departments that are commonly found in large health

care facilities.

_______ 2. List three ways in which laboratory test results are used.

_______ 3. Name at least five departments/sections common in clinical laboratory/clinical

pathology.

_______ 4. List at least three types of laboratory personnel other than phlebotomists.

_______ 5. Name 10 types of locations where phlebotomy services can be performed.

_______ 6. Describe at least three clinical duties of a phlebotomist.

_______ 7. Describe at least three technical duties of a phlebotomist.

_______ 8. Describe at least three clerical duties of a phlebotomist.

_______ 9. Describe at least five character traits of a phlebotomist.

_______10. Name at least three professional organizations for phlebotomists and other

laboratory personnel.

Competency Checklist: Quality Basics

(1) Completed   (2) Needs to improve

_______ 1. Provide three examples of external stakeholders (customers).

_______ 2. Provide eight examples of internal stakeholders (customers).

_______ 3. List five examples of how a phlebotomist may have a negative effect on quality

and/or patient outcomes.

_______ 4. List 10 examples of quality improvement assessments that could be monitored for

phlebotomy services.

_______ 5. Describe at least eight examples of preexamination/preanalytical factors that affect

phlebotomy services.

_______ 6. Describe the difference between a flowchart and a cause-and-effect diagram.

_______ 7. Give two examples of basic QC measures.

Resources

www.webMD.com Source for health and medical information

www.asq.org American Society for Quality (ASQ)

www.jointcommission.org The Joint Commission website

www.labtestsonline.org Public information about clinical laboratory testing

www.phlebotomy.com Markets numerous phlebotomy products/literature;

provides some free tips on phlebotomy practice

wwwn.cdc.gov/clia/regs/toc.aspx Current CLIA regulations

NAACLS Phlebotomy Competencies

The following NAACLS competencies are covered either completely or partially in

this chapter. By using all the resources available in the textbook and in the Instructor’s

Manual, all competencies are reinforced. Note that sometimes a competency is covered

in multiple chapters at various levels of detail and scope of coverage.

1.0 Demonstrate knowledge of the health care delivery system and medical

terminology.

1.1 Identify the health care providers in hospitals and clinics and the phlebotomist’s

role as a member of this health care team.

1.2 Describe the various hospital departments and their major functions in which the

phlebotomist may interact in his or her role.

1.3 Describe the organizational structure of the clinical laboratory department.

1.4 Discuss the roles of the clinical laboratory personnel and their qualifications for

these professional positions.

4.3 Define the phlebotomist’s role in collecting and/or transporting these specimens

to the laboratory.

7.1 Describe the standard operating procedure for a physician requesting a laboratory

analysis for a patient. Discuss laboratory responsibility in responding to physician

requests.

7.5 Describe the potential clerical and technical errors that may occur during

specimen processing.

7.6 Identify and report potential preanalytical errors that may occur during specimen

collection, labeling, transporting, and processing.

8.0 Demonstrate understanding of quality assurance and quality control in

phlebotomy.

8.1 Describe the system for monitoring quality assurance in the collection of blood

specimens.

8.2 Identify policies and procedures used in the clinical laboratory to assure quality in

the obtaining of blood specimens.

9.1 Maintain confidentiality of privileged information on individuals.

9.3 Interact appropriately and professionally with other individuals.

9.4 Discuss the major points of the American Hospital Association’s Patient’s Bill of

Rights or the Patient’s Bill of Rights from the institution.

9.5 Model professional appearance and appropriate behavior.