NHSNHS Improvement

Diagnostics

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

First steps in improving phlebotomy:The challenge to improve quality,productivity and patient experience

NHS Improvement - Diagnostics

May 2011

When considering improvement projects andparticularly when seeking to use Lean methodology,it is key that we understand the service from thepatient’s perspective. It is surprising what can beobserved and some simple suggestions forimprovement that can come from theseobservations.

Apply the same methodology to as much of theprocesses as is possible, don’t blindly accept that thecurrent process is the best way of delivering.

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Foreword

Executive summary

Why phlebotomy?

Summary of learning

Understanding the needs of patients and users

Telling the patient story

Our approach: Lean thinking - putting patients first

Project approach

Pilot sites

Case studies• Doncaster Royal Infirmary - Outpatient phlebotomy improvements• Doncaster Royal Infirmary - Increased phlebotomy productivityon inpatient wards

•Whiston Hospital (St Helens & Knowsley) - A&E Department -Reduced turnaround times (TAT), reduced admissions

•Whiston Community Clinics (St Helens & Knowsley) - Scheduling and flowof clinic start time

•West Middlesex University Hospital - Dedicated ward phlebotomist• West Middlesex University Hospital - Phlebotomy column on real-timepatient management whiteboard

•West Middlesex University Hospital - Early morning bleed•Warwick Hospital - Earlier start for bleeding patients• Russells Hall Hospital (Dudley) - Faster return of specimens from acute ward

Contacts

References

Useful reading

Acknowledgements

Contents

First steps in improving phlebotomy: The challenge toimprove quality, productivity and patient experience

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3

Foreword4

Pathology services lie at the heart of healthcare services provided to patients asthey are essential to the delivery of 70% of all clinical interventions affectingdiagnosis, treatment and long term monitoring of care. The vision for NHSpathology services puts patients first by providing services which are:

• clinically excellent• responsive to users• cost effective• integrated.

Effective phlebotomy services are the first step to providing quality pathologytests. Phlebotomy services can be provided by a range of healthcareprofessionals in a wide variety of settings. Wherever they are provided, it isessential the patients needs are considered to ensure samples are taken as localto the patient as possible, with ease of access, in a timely manner that allowsearly decision making regarding patient, diagnosis, treatment and monitoring.

The pilot sites supported by NHS Improvement have clearly demonstrated that agreater patient focus and improvements in quality of services can be achieved byapplying small measurable changes that have significant benefits.

I would endorse and commend this document as a first step in improvingphlebotomy services.

Dr Ian BarnesNational Clinical Director for Pathology

Foreword

Dr Ian BarnesNational Clinical Director forPathology

5Executive summary

In Lord Carter’s review of pathologyservices, the importance of improvingaccess to phlebotomy wasreferenced. Working in partnershipwith the Department of HealthPathology Programme, NHSImprovement supported four pilotsites to test whether Leanmethodology could meet thechallenge of improving the quality,productivity, and patient experiencefor phlebotomy services.

Multidisciplinary teams workedcollaboratively to test and implementchanges that deliver improvementsfor patients, staff and users of theservice.

Staff were trained to apply Leanmethodology to their work, theintention being to ensure continuousimprovement beyond the period ofNHS Improvement involvement.

Some of the improvementsincluded:• 59% reduction in average waiting

time for patients attending thewalk-in phlebotomy clinic

• 32% increase in phlebotomyproductivity on wards, from 8.85to 11.7 patients per hour

• 19% reduction in the turnaroundtimes for viewing a blood result inA&E from time the blood wastaken

• 100% reduction in phlebotomyservice related complaints, withpositive comments now beingregularly received

• 76 % reduction in staff absence• 22% increase in number of

patients bled within 15 minutesof arrival due to improved staffscheduling.

Executive summary

Key learning has demonstratedsuccess is achieved through:

The power of dataUnderstanding current performanceis key and enables services to getback in control of their performance,however, getting this informationcan be difficult.

Getting hold of goodconsistent data has been achallenge”

Go and seeUnless you understand theproblem and what it entailsand get all the details, youcan’t do anything. Go andlook for yourself to get theinformation.”

Phlebotomists’ calling throughpatients for bleedingOnly when we sat in thewaiting room as a patientdid we see that the systemof calling through patientswasted time, and byimplementing a simplechange we saved time.”

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Staff trained in LeanmethodologyTraining and empowering staff to usetools and techniques to focus onseeing and removing the wastes.Make use of tools and techniques tofocus the service around thecustomer.

Process mapping was a greattool to make our processvisible and highlight thewastes. Understanding ourcapacity and demand wasimportant’’.

Next stepsWe now recognise this is a vast areaof opportunity and further work isongoing which will be shared in thefuture.

Establishing measurablestandardsTo allow users and providers todeliver integrated clinical pathwaysto manage effective patient care.

Why phlebotomy?6

Each year in England approximately800 million pathology tests areprocessed and reported, costing theNHS an estimated £2.5 billion perannum, of these 90% involve thetaking of a blood sample. As withmany areas of the NHS demandcontinues to increase and thepressing challenge facing pathologyservices is how to deliver more forless. This challenge was articulated byLord Carter in his review of PathologyServices where he concluded 20% or£500 million was the scale of theopportunity. Focussing on:

• Improving access tophlebotomyTo facilitate the delivery of anefficient and high quality servicewhich is responsive to the needsand wishes of patients, withsamples collected at times and inplaces which are convenient forpatients. (Lord Carter Report of thesecond phase of the independentreview of NHS Pathology Servicesin England).

• Establishing performancestandardsClear performance standardsfor the delivery of the serviceshould be developed, and forensuring the effective use ofthe pathology service.

• Improving quality and safety:• Quality of service to the public• Clinical quality (by reducing

specimen labelling errors)• System quality.

Why phlebotomy?

Lord Carter in his review of pathologyrecognised that: ‘In this country, it isgenerally phlebotomists who collectsamples from patients in hospital andthose attending outpatient clinics”.With this scale, phlebotomy offeredthe greatest opportunity to focus ona patient facing process, bring issuesto the surface, and contribute tosignificant improvement.

NHS Improvement was tasked toaddress some of the issues ofphlebotomy services and in particular:

• Improving access to phlebotomyservices for patients and clinicians

• Improving productivity to provide amore cost effective service

• Improving patient experience• Investigating the impact efficient

phlebotomy services can have onthe whole patient pathway by:• Admission avoidance• Reduced length of stay.

7Summary of learning

What we have learned?‘Voice of the project leads’

We started out to explorephlebotomy services to understand ifimproving efficiencies, and access canhave an impact on the whole patientpathway, speeding up decisions totreat, avoiding admissions andultimately speed of discharge andlength of stay. So what has beenlearned?

It is challengingWhilst many of the trials, pilots, andimprovement suggestions seemsimple making them happen is noteasy. Common sense it seems is notcommon practice. Change is nevereasy and any improvement projectwill require dedication, focus andclear outcomes to maintainmomentum and deliver results, issueswhich are compounded when staffon pilot sites tried to driveimprovement projects as well asdoing the day job.

Allocating time and fitting itaround the day job has beenreally difficult.”

The power of dataUnderstanding current performanceis key and enables services to getback in control of their performance,however getting this information canbe difficult.

Getting hold of goodconsistent data has been achallenge.”

Summary of learning

Without national targets and goalsmeans that performance data outsideof A&E is rarely collected andanalysed. Simply understanding dailyand hourly demand allows staff to bein better control of the service,

ensuring staffing levels areappropriate to meet anticipateddemands; Delivering a predictableservice to patients whilst resourcesare used efficiently.

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“Rota management and staff capacity has improved as a resultof understanding the data. Waiting times were on the increaseand seeing where additional hours and staff were needed hashelped improve things.”

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Summary of learning8

Go and see

Unless you understand theproblem and what it entailsand get all the details, youcan’t do anything. Go andlook for yourself to get theinformation.’’

Encourage staff to view theservice from the patientsperspective. Asking the staffto sit and watch helped themto identify the key wastes.’’

When consideringimprovement projects andparticularly when seeking touse Lean methodology it iskey that we understand theservice from the patient’sperspective. It is surprisingwhat can be observed andsome simple suggestions forimprovement that can comefrom these observations.Apply the same methodologyto as much of the processesas is possible, don’t blindlyaccept that the currentprocess is the best way ofdelivering.’’

Establish measurable standards -Make them visibleBase lining the phlebotomy servicehighlighted the lack of clearmeasurable standards that werevisible to staff and users. Establishclear measurable standards inconjunction with users to ensure thatthe service is focused on patients’needs and best outcomes. If there issome measure of good performancethis seems to add clarity and focus towhat everyone is trying to achieve.

In Doncaster, a maximum 30 minutewait time standard was set.

Staff focused on the 30minute standard and this hasbeen really successful.”

Phlebotomy in isolation?The feedback from pilot sites wasthat while there were key areas offocus that delivered tangible benefitsphlebotomy in isolation cannotdeliver the significant benefits todischarge and other hospitalprocesses. When asked at the start ofthe process whether phlebotomy wasan issue many replied it was, butonce improvements were made itbecame clear that issues with otherdiagnostic pathways, bedmanagement, discharge letters andpharmacy required improvement.

Fixing phlebotomy in isolation doesnot have a profound effect on thewhole patient pathway, but thebenefits are still significant to thepatient, and can deliver efficiencies.

On the wards they havemuch bigger issues like bedmanagement and ITsystems.”

Common themesWhile there were a number ofimprovement suggestions trialledwith varying degrees of success thereappear to be some common themesand learning.

Manage with dataCollect and understand data, use it todesign the service. Manage the flowby reducing peaks and troughs andkeep the service as efficient aspossible. Share performance datawith staff and users. Establishdashboards to display metrics andempower staff to fix problems daily.

Staff trained to apply Lean toolsTrain and empower staff to use toolsand techniques to focus on seeingand removing the wastes. Make useof tools and techniques to focus theservice around the patient needs.

CommunicationMost of the sites piloted ideas toimprove communication betweenphlebotomists and ward staffproviding a range of benefits.Phoning ahead to manage demandgave phlebotomists the chance toknow what level of work was waitingon the wards and respond. Simplevisual flags to indicate whenphlebotomists were on the ward,indicating when patients had beenbled so doctors did not have to wastetime checking.

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9Summary of learning

Common wastesSignificant efficiencies were foundacross the sites by simply focusing oncommon wastes identified throughprocess mapping and observing theprocess. Reduce walking by havingphlebotomy trolleys stocked on theward, to an agreed standard.

Dedicated phlebotomistsHaving phlebotomists dedicated towards and outpatients across anumber of sites increasedproductivity as measured by bleedsper hour. It appears that this is theresult of better working betweenward and phlebotomy staff,increased communication, andphlebotomists starting to buildrelationships with patients on theward. Recognising the need forblood samples to be taken as soon asthe decision is made for the test willrequire non phlebotomy staff toprovide this service out of core hours.

Delivering samples to thelaboratoryUnderstand when ward rounds takeplace. Ensure that blood results areavailable for rounds by bleedingpatients earlier in the morning.Employ Porters or volunteers tocollect and deliver samples little andoften to the laboratory. Utilise airtube systems where available.

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Understanding the needs of patients and users10

The importance of patientfeedbackA number of websites exist wherepatients are encouraged to providefeedback on their experience. Oneexample iswww.patientopinion.org.uk

The first challenge – Have youlooked at the feedback about yourorganisation on this website?

The second challenge - Who isresponsible for providing feedback tocomments made about yourorganisation?

Understanding the needs of patients and users

The doctor saw her on Friday morning andsaid she could go home but the nurse pointedout that there were some blood test resultsthat were still to arrive and he then agreed tokeep her in hospital until Monday.Patient relative ”My partner was waiting in A&E (after triage)for two hours while blood tests could havebeen run - eventually when blood wastaken she had to wait another two hoursfor results.Patient relative”

Waiting for resultsseemed to be adelaying factor - I feltthat more rapidresults could havesaved some of my bedoccupation time.Patient

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11Telling the patient story

Before embarking on wholesalechanges to phlebotomy services it isimportant to understand and definevalue from the patients’ perspective.This is central to understanding whatis important to patients and cliniciansand provided areas to focus theimprovement. This took the form ofdata analysis, stakeholder and stafffeedback, and patient experience.

The end-to-end pathway providedevidence of the improvementsalready made in laboratory processes,and focussed on the potential forimprovement in other parts of thepathway

Often we only look at the laboratory,but it is in the whole pathway wherethe big wins appear to be.

The Emergency Care Pathway:Whiston HospitalThere were perceived delays in thelaboratory that were causing patientsto breach the A&E four hour target.As a result of working with theEmergency department team wehave been able to identify thecomplete blood pathway and haveengaged with key staff from theEmergency department.

Telling the patient story

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

50 mins 28 mins 47 mins 1 hour 20 mins

Arrival to collection Collection to booked

Booked to reported Reported to viewed

Long delays from resultavailable to result viewedor acted upon

Long delays from request to bleed(ownership, capacity, productivity)4 Hour A&E Target

Time from arrival in department to result viewed

The inpatient pathwayThe following is a patient story of how poor processes can have adramatic effect on the patient:

• Specimen taken 7.30 a.m. (for Gentamicin levels) - phlebotomist noted‘patient very collapsed and not enough blood to do U&E, Full BloodCount and Gentamicin’

• Sample arrived in the laboratory 8.30 a.m.• Local lab analyser has been defective for the last 14 months (policy is all

microbiology samples are analysed at hospital 10 miles away)• Lab staff spent two hours trying to contact the Senior House Officer (SHO)

to ascertain which test was more important the U&E or the Gentamicin?• Sample put on first transport to external lab at 10.30 a.m.• Result back on ICE (I.T. System) at 11.45 p.m.• SHO contacted at 1.46 a.m. regarding result• Phlebotomist didn’t realise the significance of not being able to get

blood out for this patient at 7:30 a.m. (i.e. collapsed from septic shock?)• Nurses left in a quandary as to whether to give the three more doses of

Gentamicin due at 8.00 a.m. 4.00 p.m. and midnight.

PATIENT STORY

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Our approach: Lean thinking - putting patients first12

At the heart of Lean thinking arecustomers, our patients, and seekingto understand what parts of ourprocesses they believe are valuable. Inour experience with or as patients wemay all agree that of value is safe,timely, high quality care. Very few ofus would consider waiting, queuing,endless paperwork, or mistakes to bea valuable part of any service wewould be prepared to pay for.

The key to lean improvement is:

Go see, ask why, andunderstand the rootcause of the problemyou are solving.

David Fillingham, Lean Healthcare

Our approach: Lean thinking -putting patients first

Too often, patients are expected to fit aroundservices, rather than services around patients.Liberating the NHS –Department of Health White Paper (December 2010)

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Lean thinking is a way of streamlining thepatient journey and making it safer, by helpingstaff to eliminate all kinds of waste and to treatmore patients with existing resources.

Jones, www.leanuk.org

Before

After

Any process or value stream Improved customersatisfaction

• Reduced waiting

• Better delivery

• More capacity

• Better quality

• Improved productivity

• Improved safety

Lean attacks waste here

Work ... value added time Wait/waste ... non value added time

Lead Time / Cycle Time

Reduced waste, improved customer experience

The Benefits of Lean

13Our approach: Lean thinking - putting patients first

1. Specify value - The elimination ofwaste is the main characteristic ofLean. Waste is everything thatdoesn’t add value to the patient orprocess. There are three types ofwork:

• Value add – When you are addingvalue to the patient/process (e.g.prescribing medication, providingphysiotherapy, reporting an image)

• Necessary waste – When you arenot adding value but it is anecessary step. (e.g. incubation in amicrobiology laboratory)

• Unnecessary waste – Where youare not adding value and thesesteps could be removed (e.g.walking to get or find items,waiting for staff, machines andmedication).

The wastes can be remembered bythe name TIM A WOODS (Leanoffice at Cooper Standard,Plymouth UK)

Continuous improvement in Leanmethodology focuses on five key steps

Introduce Standard WorkingRemove Waste

Set Up Visual ManagementEliminate BatchingIdentify Root Cause

Specify VALUE fromthe customer viewpoint

Make valueFLOW

initiate PULL in linewith customer demand

PursuePERFECTION in

quality andquantity bycontinuous

improvement

Identify theVALUE STREAMand removewaste

2. Identify the value stream steps- A current state value stream map isa visual representation of all theactions currently required to deliver aproduct or a service.

3. Make value flow - Flow is thecontinual movement of value addingactivities from the beginning to theend of the value stream. Processeswhich add value to the patientshould not be held up by any nonvalue adding steps or waste in thesystem.

4. Pull value through the processfrom actual demand - Flow and pullwork to keep the entire value streammoving. “Flow where you can, pullwhere you must” Jeffery K. Liker, TheToyota Way, 2004

5. Continually improve and strivefor perfection - Continuousimprovement is the final leanprinciple, which is to strive forperfection through continuousimprovement. It is important todevelop staff and give them thecapability, autonomy andempowerment to solve the problemsas they encounter them on a dailybasis.

More often than not theprocess is to blame not thepeople. To improve theprocess do so by striving for‘clinical excellence inpartnership with processexcellence’.”

Continuous improvement inCytology, NHS Improvement

T TRANSPORT

INVENTORY

MOTION

Reference: ‘Bringing Lean to Life’,NHS Improvement

I

M

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W

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O

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S

AUTOMATING(an inefficient process)

WAITING

OVER PROCESSING

OVER PRODUCTION

DEFECTS

SKILLS UTILISATION

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Project approach14

The experience from previouslearning has demonstrated that thefactors in the graphic on the right arevital to achieving sustainableimprovement.

Understand the current processIn healthcare, we are used to takingclinical measures such astemperature, pulse, blood pressure,respiration rates, urine outputs etc inorder to understand the currentstatus and demonstrate if conditionsare getting better or worse.

Project approach

To improve your current process, datais required to understand the rootcause of the problem you are tryingto address, a set of measures needto be agreed.

Measures might include:• Quality – End to end

turnaround times• Cost – Improve productivity• Morale – reduce staff time doing

wasteful activities• Patient experience – reduction in

waiting times.

It isn’t always easy to collect data forthis baseline. If you can’t get theinformation from the electronicsystems, you will need to collect theinformation manually.

Data and measures are alsoimportant to demonstrate and provethat change has occurred, and whatdifference this makes for all thoseinvolved in the process includingpatients and staff. Whether thechange was a success or a failure,you still need to demonstrate it!

Factors for achieving sustainable improvements

Map the processA critical starting point in anyproblem solving or improvementwork is to map the process in itscurrent state. One of the tools usedto capture the current state or ‘as is’performance is the value stream map(VSM).

Current State VSMA current state value stream map is avisual representation of all the actionscurrently required to deliver a productor a service. The output however ismore than just the current state, you

Dataanalysis

Evaluateand

sustain

Pilotsolutions

Identifythe

wastes

Project timeline

15Project approach

PLAN

DO

ACT

STUDY

ObjectiveQuestions andpredictions (why)Plan to carry out thecycle (who, what,where and when)

Carry out the planDocument problemsand unexpectedobservationsBegin analysisof the data

Complete theanalysis of the data

Compare data topredictions

Summarise whatwas learned

What changesare to be made?

Next cycle

PDSA cycle for learning and improvement

Once suggestions for improvementhave been tested on a smaller scaleand demonstrated they work, onlythen can we we roll out thosechanges across the whole service.This will require planning,consideration for potential obstacles,and a plan to manage those changes.However, changes are made in theknowledge that they have beenpiloted, have demonstrated theirsuccess and how they improve theprocess.

Continuous improvementContinuous improvement is the finalLean principle, which is to strive forperfection by embracing the Leanphilosophy and tools. The staff are afundamental part of Lean. It isimportant to develop staff and givethem the capability, autonomy andempowerment to solve the problemsas they encounter them on a dailybasis. Teaching and expectingrigorous problem solving by all staff is

also look to map where the value inthe process happens, and wherewaste in the process is. This thenguides group discussions andproblem solving to produce tangiblesolutions and ideas to reduce thewaste and increase the value in theprocess. Remember as defined earlierin this booklet value can only bedefined by the end customer. Inhealthcare the customer is usually thepatient. Value is any activity thatdirectly contributes to satisfyingneeds of the patient. Any activity thatdoesn’t add value is defined aswaste.

Future State VSMOnce you understand the currentpicture of what really happensthroughout the value stream, you canbegin to agree what needs to happenand then analyse the gap betweenthe current and future states. Fromyour current state map you will beable to identify where the significantproblems occur. This might be themost prevalent waits and delays, thelargest amount of work in progressbetween process steps or wherethere is considerable duplication.Once the future state Value StreamMap is completed, it is then essentialto review measures, analyse the gapbetween current and future stateand then agree an action plan to trialthe changes.

Take action and pilot solutionsTake action, pilot suggestions forimprovement, measure the effect andcontinue to improve until you have aworkable solution to reduce waste.Even small scale pilots can provideenough data and feedback toestablish if the solution deliversbenefits and increases value, beforerolling out large service wide changesthat are untested.

the only sustainable way to strive forperfection.

Areas to focus onHaving defined patients’ value, themapping, waste identification andstaff discussion began to focus onkey areas and potential forimprovement:

• Understand the end to endpathway – don’t assume the faultlies with the laboratory

• Capacity and demand –understand daily/hourly demandand capacity

• Use visual management todemonstrate performance

• Engagement with clinical teams• Productivity – How to improve the

number of patients bled per hour• Use the evidence to design the

service.

The pilot sites16

West Middlesex UniversityHospital NHS TrustThe West Middlesex UniversityHospital is a busy urban acutehospital located in Isleworth, WestLondon providing services primarily toresidents of the London Boroughs ofHounslow and Richmond uponThames. Employing some 2,250people (including our partners inEcovert FM), the hospital has over400 beds. The Trust has an annualbudget in excess of £130 million andprovides services to a population ofaround 400,000.

The Dudley Group of HospitalsNHS Foundation Trust (Russell’sHall Hospital)Russell’s Hall Hospital is the largest ofthree hospitals in The Dudley Groupof Hospitals providing the full rangeof surgical and medical specialties forits inpatient services, together withsome outpatient and therapy serviceswith over 750 beds.

South Warwickshire NHSFoundation Trust (WarwickHospital)While working with our pilot sites,NHS Improvement had anopportunity to link with SouthWarwickshire NHS Foundation Trustwho are taking part in a flow costand quality programme with theHealth Foundation.

The pilot sites

NHS Improvement worked withthe following pilot sites:

Doncaster and BassetlawHospitals NHS Foundation Trust(Doncaster Royal Infirmary)Doncaster Royal Infirmary is one ofthe key hospitals in the Doncasterand Bassetlaw Hospitals NHSFoundation Trust. The hospitalprovides a full range of servicesappropriate to a large district generalhospital in 800 beds. Each year thehospital treats around 150,000patients along with 95,500 A&Epatients (combined figures forDoncaster Royal Infirmary andMontagu Hospital).

St Helens and Knowsley TeachingHospitals NHS Trust (WhistonHospital)Whiston Hospital is one of twoMerseyside hospitals (along with StHelens Hospital) managed and run bySt Helens & Knowsley TeachingHospitals NHS Trust. The new hospitaloffers the full range of acutehealthcare services along withspecialist burns care through theMersey Regional Burns and PlasticSurgery Unit. It has 15 operatingtheatres, diagnostic facilities, andover 800 beds.

Summary59% reduction in average waitingtime for patients attending the walk-in phlebotomy clinic at DoncasterRoyal Infirmary (DRI)

Understanding the problemPatients attending the phlebotomywalk-in service at DRI often had towait over an hour to have theirblood taken. Regularly it wasstanding room only in the waitingarea, staff morale was low and staffabsence was high. The long waitingtimes for phlebotomy led to knock-on problems in outpatient clinics,leading to complaints from cliniciansand patients. A high number ofprimary care patients also attendedthe walk-in service and were equallydissatisfied with waiting times.

The phlebotomy area was co-locatedwith the pathology laboratory so alloutpatients had to travel round thehospital site to have their bloodtaken. Patients reported to areceptionist as they arrived, whochecked their identification andplaced their request form in a box inorder of arrival. As eachphlebotomist became free, they tookthe next request form from the box,walked out into the waiting area,called the patient by name andwaited for the patient to respondand return to the blood taking areawith them.

How the changes wereimplemented

• Numerous formal and informalmeetings and discussions with thephlebotomy team to agreechanges.

• The walk-in clinic relocated to themain out-patient area.

• A patient queue managementsystem was installed. This systemenables each phlebotomist to callthe next patient through to theircubicle as soon as they are ready,using a small keypad. The patientssee a number display and hear anaudible announcement in thewaiting area. The keypad informsthe phlebotomist how long thepatient has waited to be called,and how many people are in thequeue.

• A dashboard was developed,utilising the output data from thepatient queue managementsystem. The team print thedashboard to create a very visibledisplay of daily, weekly andmonthly performance.

• Demand information wasrequested from every inpatientward each morning before thephlebotomy round started to assistoverall rota management.

• The staff rota was co-coordinatedacross inpatient services and thewalk-in clinic to match capacity todemand as closely as possible,with a number of changes beingmade over time.

A receptionist recorded the waitingtime for phlebotomy on the hour,every hour over many months.

Staff issued a questionnaire to allpatients attending the walk-in clinicthroughout the week of 23-27November 2009, to providefeedback on why they had chosen toattend DRI for phlebotomy and togain information about how longthey had to wait.

Phlebotomists sat in the patientwaiting area and observed theprocess from the patients’ point ofview. Phlebotomists timed eachstage of the process and thenagreed which steps were valuecreating and which were ‘waste’.

Doncaster Royal InfirmaryOutpatient phlebotomy improvements

ONE.CASE STUDY

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Measurable outcomesand impact• 59% improvement in average

waiting time.• Average waiting time improved

from 18.6 to 7.6 minutes.• 53% improvement in maximum

waiting time• Maximum waiting time reduced

from 87 to 41 minutes (averagesper month)

• Reductions in average andmaximum waiting times achieveddespite increasing demand, andwith no increase in staff numbers.

• 12,699 hours of waiting timesaved since improvement work(approx. 1,154 less waiting hoursper month).

• Feedback has been hugelypositive, transforming 10 writtencomplaints in 2009/10 to 21written compliments in 2010/11along with hundreds of verbalcompliments.

The following quotations are takenfrom some of the writtencompliments received:

I have been attendingphlebotomy for 12 years as apatient of Dr M. Since yourreorganisation in the last fewmonths, the reduction inwaiting time is bothsignificant and welcome.Well done in improving somuch the patientexperience"

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This is so much better than before, in and out,clean area and friendly staff”

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• Feedback from clinicians has beenequally positive, with manyconsultants contactingphlebotomy staff to inform themhow pleased they are that theirpatients are being seen quickly.

• No issue with seating in thewaiting area as the queue doesnot build up.

• Most outpatients do not have totravel round the hospital corridorsto have their blood taken, asphlebotomy is now co-located inthe main outpatient area. Inaddition, the free park and ridebus stops just outside thephlebotomy and outpatientwaiting area.

• Staff morale has improvedsignificantly. The phlebotomyteam meets regularly in workhours. Communication foldersand notice boards have beenintroduced and most staffparticipate in social functionsoutside work:• Since the improvement work

commenced, staff absence hasreduced from 6.6% to 1.6%over the last twelve months.

• 926 more staff hours at workthat were previously absent in ayear.

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enta

ge

abse

nce

Reduction in waiting time while activity increases

Staff absence - Phlebotomy (DRI)

Ideas tested which weresuccessful• Installing patient queue

management system:• Removing waste (phlebotomist no

longer going into waiting area tocall patient).

• Phlebotomist able to see waitingtime of current patient andnumber of patients in queue onkeypad.

• Dashboard displays created usingdata from system – to makeperformance very visible. Daily,weekly and monthly dashboardsare used (see examples on theright).

• Data from system used to matchstaff rotas (capacity) to demand asclosely as possible.

• Reducing phlebotomy hours oninpatient wards and moving themto walk-in clinic.

• Relocating to main outpatientarea.

How this improvement benefitspatients• Significant reduction in waiting

time for patients.• On average every patient waits

only 7.6 minutes, rather than18.6.

• Visual and audible display inwaiting area, so improvement forpatients with hearing difficulties.

• Outpatient clinics not held up bypatients queuing to have bloodtaken.

Daily dashboard example

20

21

How will this be sustained,potential for the future andadditional learning• Ongoing use of data by

management team andphlebotomists.

• Visible displays of performance tostaff and patients.

• Roll-out of patient queuemanagement system, staffprocesses and rotas to Bassetlawhospital walk-in clinic (positivepatient feedback and evidence ofwaiting time improvements usedto achieve business case approval).

• Fine-tuning of staff rotas in linewith demand.

• Data used to support recruitmentas activity increases (evidence forfunding application).

ContactSarah BaylissEmail: sarah.bayliss@dbh.nhs.uk

Monthly dashboard example

22

Doncaster Royal InfirmaryIncreased phlebotomy productivityon inpatient wards

TWO.CASE STUDY

Summary32% increase in phlebotomyproductivity on wards, from 8.85 to11.7 patients per hour.

Understanding the problem• Phlebotomists were frequently

reaching the end of their shift,running out of time, and leavingsome inpatient wards without aphlebotomy service. Differentphlebotomists went to each wardeach day, working in pairs, andthere was little or no teamworkbetween phlebotomists and wardstaff.

• The phlebotomists were unable tobleed some patients.

• The ward phlebotomists wouldcollect together to get specimensready for transport to thelaboratory, have a break, andwould phone the manager toinform her how many patients hadnot yet been bled.

• Staff morale was low and absencelevels were high.

• Feedback from wards was poor.

Ward 26 (a respiratory medical ward)agreed to work with the phlebotomyteam to improve the service.

Phlebotomy representatives observedwhat was happening on ward 26,then met with a team of staff fromward 26, listened to their views ofthe phlebotomy service andascertained what changes theywould like. The phlebotomists thenshared this information with theircolleagues.

A team of phlebotomists and wardstaff undertook a process mappingexercise. Phlebotomists timed eachstage of the process and the teamthen agreed which steps were valuecreating and which were ‘waste’.Changes were agreed andimplemented to reduce ‘waste’ andthereby increase value as apercentage of the total service time.

How the changes wereimplemented• Suggestions from staff from

process mapping session and othermeetings.

• Demand information wasrequested from every inpatientward each morning before thephlebotomy round started.

• The staff rota was coordinatedacross inpatient services and thewalk-in clinic to match capacity todemand as closely as possible,with a number of changes beingmade over time.

• Every ward was asked to indicatetheir ideal time for thephlebotomy round.

• Separate ward and walk-in clinicphlebotomy teams wereestablished.

• Only one phlebotomist goes toeach ward instead of working inpairs, so they are on the ward forlonger; therefore, there is a greateropportunity for the doctor to placeadditional requests.

• ‘Phlebotomist on the ward’magnets are displayed on theward ‘status at a glance’ boards toindicate their presence.

23

• Same phlebotomist on each wardeach day, so soon built rapportwith ward team. Also got toknow ‘their’ patients, so fewerunable to bleed events.

• Ward phlebotomy trolleys wereestablished, rather thanphlebotomist having to transfer atrolley between wards (reducetime waiting for lifts, and improveinfection control) and a standardlayout agreed for each trolley.

• Pilot on ward 26 to test outchanges.

• Discussion at matron’s meetings toagree roll-out across all wards.

• Proposed trolley changescoordinated as part of electronicrequesting and reporting system.

Measurable outcomesand impact• 32% improvement in

productivity on inpatient wards.• 33% reduction in phlebotomy

staff hours on inpatient wards,yet wards no longer left without aservice.

• Positive feedback from ward staffand phlebotomists.

• Reduction in number of ‘unable tobleeds’.

• Staff morale has improvedsignificantly and phlebotomistabsence has reduced from 6.6%to 1.6%. The phlebotomy teammeets regularly in work hours.Communication folders and noticeboards have been introduced andmost staff also participate in socialfunctions outside work.

• 926 more staff hours at work thatwere previously absent in a year.

Ideas tested which weresuccessful• Establishing a ward-based

phlebotomy team.• Named phlebotomist per ward.• Only having one phlebotomist to

service each ward, so they are onthe ward for a longer period.

• Displaying ‘phlebotomist on ward’magnets.

• Delaying coffee breaks until wardwork is completed.

• Reducing phlebotomy hours oninpatient wards and moving themto walk-in clinics (matchingcapacity to demand).

• Changing the order in whichphlebotomists attend each ward toalign the service with wardrounds.

• Varying how specimens aretransported to the laboratory toensure they are processed as soonas possible.

• Use of ward-based trolley forphlebotomy, rather than taking atrolley from phlebotomy roundevery ward.

• Standard layout for every trolleyagreed and implemented.

How this improvementbenefits patients• Happier staff.• Phlebotomist gets to know the

patients on their wards, which:• increases their success rate at

obtaining high quality bloodsamples.

• means they can spot when arequest form is missing.

• builds rapport with the patientand helps to put them at ease.

• Enables blood to be taken as soonas possible after the clinicianrequests it, and transported to thelaboratory for analysis, therebysupporting timely treatment ordischarge of patients.

10

9

8

7

6

5

4

3

2

1

0

Month

May09

Apr09

Jun09

Jul09

Aug09

Sep09

Oct09

Nov09

DecDec

Jan10

Feb10

Mar10

Apr10

May10

Jun10

Jul10

Aug10

Sep10

Oct10

Nov10

Dec10

Jan11

Feb11

Mar11

Phlebotomy

Pre improvement Post improvement

Perc

enta

ge

abse

nce

Staff absence - Phlebotomy (DRI)

24

How will this be sustained,potential for the future andadditional learning• Ideas piloted on ward 26 have

been rolled out to other wardsfollowing discussion at matrons’meetings.

• Use of ward-based phlebotomytrolley to be rolled out as part ofthe electronic requesting andreporting system implementation(a ‘clinical cart’ is being developedthat will combine provision of IThardware and software with thefacility to transport phlebotomyand other clinical consumables).

• Ongoing use of data bymanagement team andphlebotomists.

ContactSarah BaylissEmail: sarah.bayliss@dbh.nhs.uk

25

BackgroundWhiston Hospital is a new PFI whichopened in March 2010, with 900beds, approximately 250 A&Epatients attending per day,pathology had approximately 100patient bloods per day. The locationof this unit was approximately 100meters away from the existingpathology service. National targetfour hour wait – impact on movingpatients / admissions high – chargesto PCT, how could this be challenged(see EAU on the following page).

SummaryAs a result of working with theEmergency department team wehave been able to identify the end-to-end blood pathway and haveengaged with key staff from theEmergency department. A measureof the end-to-end blood pathwaywas undertaken, and a processmapping day held to map thepatient’s journey. This processproduced an action plan andmeetings were then held every twoweeks to monitor the introduction ofthe changes.

The process showed an overallreduction in the blood pathway of19%.

Understanding the problemTo understand and measure theperformance of the blood pathwaywithin our Emergency servicesdepartment. To investigate theimpact the blood pathway has onhospital admissions.

This engagement with ouremergency department identified apossible link between the bloodpathway and admissions to theTrust. We were confident that theexisting blood pathway could beimproved and wanted to use thehospital admissions data as anindicator / measure of thisimprovement.

Data collection for this area fallsunder the following headings:• Emergency blood pathway

• Patient arrival time in theemergency department -Arrived

• Patient has blood collected -Transport

Whiston Hospital (St Helens & Knowsley) - A&E DepartmentReduced turnaround times (TAT) andreduced admissions

THREE.CASE STUDY

• Patient blood samples arebooked in to the pathologycomputer - Received

• The pathology process iscompleted (i.e. Emergencydepartment staff are able toview results) - Authorised

• Results are viewed in theEmergency department -Viewed.

• Hospital admissions (expressed asa percentage).

Data was extracted electronicallyfrom both the emergencydepartment system and thepathology computer. Some manualdata extraction was also carriedparticularly for results viewed. Timecollected was only provided onapproximately 40% of requests.Completed data sets were processedand the outcomes discussed toimprove the level of understandingat the appropriate workstreammeetings.

3.50

3.21

2..53

2.24

1.55

1.26

0.57

0.28

0Arrival in AED

to sample collectedCollected to boked

in lab systemBooked in lab toresults available

Results availableto results viewed

Total

June

Turn

aro

un

dTi

mes

0.500.40

0.28 0.25

0.47 0.52

1.20

0.47

3.25

2.44

October

Phlebotomisttrialled in AED

POD reliability improvedPorter collects sample

when POD down

Raised awareness in AEDCoordinator roles

stablished

19% reductionoverall

Whiston A&E blood pathway

26

OutcomesAll relevant departments wereengaged in the process mappingevent. Actions were captured in aplan; this was then delivered overseveral weeks with varying success.

The following changes were made:• Take blood samples earlier in the

patients journey.• Transport changes

• Trust air tube system – Improve• Improve air tube failure

reporting process• Improve access to porters

when/if air tube fails.• Action pathology blood results

earlier by viewing using patientenquiry or scrolling screens.

• Improve team work between Trustphlebotomy team and emergencyassistants, this resulted inimproved coverage of previouslyun-staffed sessions.

• Re-launch clinical nursing lead forevery shift to provide support andstandard working.

• Frequent meetings to discuss andsustain improvements / introducenew changes.

Following on from the action plan itwas clear that we needed to identifythose patients that had beenadmitted to hospital due to a delayin the blood pathway. Afterdiscussions with the medicaladmissions unit ward manger we feltit was best to concentrate on a unitcalled the emergency admissionsunit.

Emergency AdmissionsUnit (EAU)This 16 bed unit accepts patients fora whole variety of reasons /conditions. We decided to look indetail at four days over a period oftwo weeks. To gather informationwe used the EAU ward admissionsregister and the trust ElectronicDocument Management System(EDMS) for all patients admitted overthe period. See results above.

The outcome of this work wasshared with the Emergencydepartment mangers that used thisand other data to introduce plannedpathways for specific conditions. Thiswork is ongoing and therefore theoutcome can not be fully assessed atthis stage. It is felt however that itwill have an impact on the hospitaladmission rate.

Challenges• Consistent engagement over time.• Data quality and understanding of

the impact.• Extraction of data, time

consuming and therefore this hadto be limited.

• Introduction of changes /timescale.• Multi team working, efforts being

made to co-ordinate the differentteams.

• Changes to targets.• PCT structure /changes.

ContactChris WestcottEmail: chris.westcott@sthk.nhs.uk

100

90

80

70

60

50

40

30

20

10

0Awaiting

Bed

Nu

mb

erad

mit

ted

91

ExtendedClinical

Pathway(eg Troponin)

21

Waiting forBloodResults

8

Waiting forTransport

4

Waiting forSpecialistOpinion

(eg Orthopaedics)

19

Waiting forImaging

2

Other

14

Reasons for Admission

Reasons for admission

27

Whiston Community Clinics (St Helens & Knowsley)Scheduling and flow of start time

FOUR.CASE STUDY

Along with other national sites weset out to answer the followingquestions:

• Are patients waiting excessive daysbefore having blood taken?

• Are patients waiting for longperiods when they arrive at aphlebotomy session?

• Are patients travelling excessivelyto have blood taken?

• How is the capacity in relation tothe demand?

Understanding the problemOur initial plan was to concentrateon primary care based staff and thenincorporate any transferableimprovements/changes to oursecondary care based team. Asthere was no data available withregards to accessing phlebotomy wecollected data to form a baseline andenable us to understand the process.All the data needed to be collectedmanually. On analysing this data itwas felt that there were long waitingtimes for patients to be able to gainaccess to phlebotomy clinics andthen each patient would haveencountered long waits in varioussettings for their blood to be taken.

• The data showed that thecommunity clinic we had chosenshowed delays from the requestbeing made to the patient arrivingto have blood taken but that thesewere predominately due to patientchoice – No action taken.

• The data showed patients whohad arrived at a communityphlebotomy session were waitingan excessive amount of timebefore they had their blood taken– Main focus for action.

• The data showed the distancepatients travelled was notexcessive, so choice wasacceptable – No action taken.

• The demand on occasions didexceed capacity but this was feltto be limited, this area needs to bereviewed on a regular basis as thepercentage increase in workloadchanges.

This years increase for primary carewill see a further 28,000 (M11forecast) patients being bledcompared to the previous 12 monthsof April 09 – March 10. This equatesto another 1.65 WTE phlebotomyhours required to deliver thisadditional capacity - Action taken,we have increased our service bythree additional community sites allat the request of the PCT’s, lessonslearnt have been used at these newsites

We undertook reviews of severalphlebotomy areas, one of theseareas had recently been handed overto our team and we had changedthe service significantly but someissues remained. This service wasbased in a new PFI PCT build calledNewton Community Hospital. Thephlebotomy service was an ondemand service. All patients werehanded a number on arrival by thePCT receptionist, and once our limithad been reached for that session allother patients were then turnedaway.

With demand and service provisionoffset, the majority of patientswaited at least half an hour or moreto be bled:

• 50% of patients waited up tohalf an hour to be bled.

• 80% of patients were seen in 50minutes from arrival.

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge

0 to 5mins 6 to 10

mins

11 to 15mins 16 to 20

mins

21 to 25mins 26 to 30

mins

31 to 35mins 36 to 40

mins

41 to 45mins 46 to 50

mins

51 to 55mins 56 to 60

mins

61 to 65mins

71 to 75mins66 to 70

mins

Time from arrival

Percentage time to be seen from arrival

28

Our team decided to drill down ourdata and improve the phlebotomyservice at our chosen clinic; welooked at all the factors below:

• Capacity and demand.• Service delivery - start time.• Patient flow.• Staff moral / patient experience.

All of the baseline data requiredcould be easily accessed with theexception of staff moral / patientexperience. This was collected byimproving staff feedback with seniormembers of staff and monitoringpatient complaints from this clinic.

By starting the service 30 minutesearlier the phlebotomist was able toreduce the number of patientswaiting more than 30 minutessignificantly. We also provideadditional phlebotomy resource on aTuesday. We are reviewing therequirement for an afternoonsession; however this will depend onfuture workload and demand.

From November 2009 – October2010 we received eight complaints,most of these were in relation topatient flow and excessive waitingtimes. A few of these were centeredon patients being asked to return tothe clinic another day due to thecapacity being exceeded. Thenumber of patients bled per threehour session on average is 45. Thedata showed that within the firsthour over 25 patients wereattending the clinic which made itdifficult for a single phlebotomist tomatch the demand.

ResultsJanuary 10• 50% patients bled within 30

minutesOctober 10• 72% patients bled within 30

minutes.

January 10• 19% patients bled within 15

minutes.October 10• 41% patients bled within 15

minutes.

Overall average time to be bled hasfallen from 33 minutes in January2010 to 23 minutes in October2010.

250 patients are bled per week, onaverage 10 minutes per patient timesaved, this equates to more than2,100 hours patient waiting (or 90days) saved per year.

The PCT staff within the clinic arehappier as fewer patients arecomplaining, our phlebotomy staffare happier and are returning to themain St Helens Hospital base earlier,this helps productivity at this site andalso staff morale as they aresupporting their colleagues at StHelens Hospital over lunch times.

Blood samples are returning to thelaboratory earlier thereforeturnaround times (TAT) andreporting to the GP will beimproved, with the number reportedon the same day being higher thanprevious.

ContactChris WestcottEmail: chris.westcott@sthk.nhs.uk

80

70

60

50

40

30

20

10

0% in 15 minutes

Perc

enta

ge

18.8%

40.7%

% in 30 minutes

50.3%

71.9%January 2010 October 2010

Percentage bled

29

Improved relationship betweenphlebotomists, doctors, staff on thewards and patients by providing adedicated phlebotomist to the pilotwards. Extending the existing twoweek phlebotomy ward rota to threemonths.

Understanding the problemProject problem statement: Theaim of the project was to improvethe efficiency and flow of theinpatient phlebotomy pathway fromthe moment the request is madethrough to the result being viewed.By improving this we then hope toimpact on delays in results beingdelivered which in turn shouldreduce length of stay by allowingprompt and informed decisions to bemade with regards to patientdischarge.

Identification: The issue of a lack ofteam working between thephlebotomists and the ward staffwas identified via initial feedbackfrom the phlebotomy team whenthe project was first introduced.Phlebotomists described feelingisolated and almost like an intruderon the wards. Ward staff anddoctors both reported not being sureif the phlebotomist was on the wardas they didn’t recognise them.

Data collection: Qualitative datawas collected via discussion andfeedback at phlebotomy teammeetings, junior doctor meetingsand meetings with nursing staff andsurveys.

Waste: The feedback showed thefrequent change over ofphlebotomists on the pilot wardswas leading to low morale for thephlebotomists. It was alsointroducing delays with doctors notrealising who the phlebotomistswere and subsequently not passingnewly created urgent requests tothem when they were on the wards.

How the changes wereimplemented• Solution identified – A dedicated

phlebotomist on each of the pilotwards was proposed, and threemonths was agreed as areasonable period of time. Alonger period was not thought tobe practical as different wards andoutpatient clinics accommodatequite different patients, so it isimportant for the phlebotomists’

personal development to gainregular experience in each of theseareas.

• A dedicated phlebotomist wasallocated to each of the pilotwards for a three month period.

Measurable outcomesand impactWorking relationship between thephlebotomist and the ward staff wasimproved. Phlebotomists alsoreported an additional benefit ofgetting to know the patients betterwhich facilitated the phlebotomyprocess. This was found to beespecially true on the medical wardwhich had a slower turnover ofpatients compared to the acutemedical unit. The number of patientsbled was also seen to increase overthe duration of the three monthroster period on both wards.

West Middlesex University HospitalDedicated ward phlebotomist

FIVE.CASE STUDY

12

10

8

6

4

2

0

Week commencing

1/11/10 8/11/10 15/11/10 22/11/10 1/12/10 6/12/10 13/12/10 20/12/10 27/12/10

MAU/AMU1 (SC) OST1 (DM)

Nu

mb

ero

fp

atie

nts

ble

dp

erh

ou

r

Dedicated Phlebotomist Trial: Rate of Bleedfor AMU1/MAU & Osterley 1 Dedicated

phlebotomists onholiday so trialsuspended

30

Ideas tested which weresuccessful• The idea of introducing a

dedicated phlebotomist onto thewards to improve team workingbetween the doctors, ward staffand the phlebotomy team camefrom feedback given by the allthree staff groups when theproject was first initiated.

• A process mapping session washeld involving all staff groupsinvolved in the phlebotomypathway i.e. junior doctors,nursing staff, phlebotomists andlaboratory staff. This sessionhelped to develop the solution ofintroducing a dedicatedphlebotomist.

How this improvementbenefits patientsThe benefit to the patients has comefrom ensuring that doctors, wardstaff and phlebotomists work as ateam. Leading to bettercommunication which in turnfacilitates the patient’s phlebotomypathway and reduces delays due tolack of communication. Patients onthe longer stay medical ward alsobenefitted from getting to knowtheir phlebotomist over the course ofa few days.

How will this be sustained,potential for the future andadditional learningThis initiative has led to an improvedworking relationship between thedoctors, the ward staff and thephlebotomists and has helped toimprove the efficiency of thephlebotomy rostering to continue toprovide a dedicated phlebotomist onall wards is being put in place.

ContactSian SuttonEmail: sian.sutton@wmuh.nhs.uk

31

Improved communication betweenphlebotomists and doctors to ensurethat any outstanding blood testrequests left following thephlebotomists round are highlightedimmediately so that doctors/nursingstaff can arrange to take the bloodthus minimising delays to patientresults being returned.

Understanding the problemProject problem statement: Theaim of the project was to improvethe efficiency and flow of theinpatient phlebotomy pathway fromthe moment the request is madethrough to the result being viewed.By improving this we then hope toimpact on delays in results beingdelivered which in turn shouldreduce length of stay by allowingprompt and informed decisions to bemade with regards to patientdischarge.

Identification: The problem of poorcommunication between thephlebotomists and the doctors wasidentified via initial feedback fromdoctors on the pilot areas when theproject was first introduced. Doctorsexplained how they were unawareof which patients had been bled bythe phlebotomist and which patientsstill required bleeding following thephlebotomists ward round. This ledto doctors sometimes having thefalse impression that their patienthad been bled only to find out a fewhours later when searching for thetest results that the bloods had notbeen taken, thus delaying the test,result and possible discharge of thepatient.

Data collection: Data was collectedmanually and electronically for thewhole pathway, via thephlebotomist’s daily paper wardrecord sheet, the ICE order commssystem and Winpath lab computersystem.

Data collected:• Date/time of request.• Date/time patient bled.• Date/time logged on laboratory

system.• Date/time result reported.

Waste: The data from request tobleed time highlighted a largenumber of cases where there werelong gaps between the requestbeing placed and the patient beingbled. Feedback from the doctorshowever showed that many of theserelated to requests that were placedwith the intention of their being along gap i.e. cases where the doctorhad placed the requests in theevening ready for the next morningwith the intention of the patientbeing bled in the morning and notthat night. However there werecases identified by the doctors wherethe expected morning bleed had nottaken place and patients had notbeen bled until mid afternoon thusintroducing a 2-4 hour delay.

How the changes wereimplemented• Solution identified – phlebotomy

column added to the patientmanagement whiteboard on eachof the two wards. Doctors toindicate which patients requiredbleeding by placing a (/) in thecolumn against the patient’sname. The phlebotomist at theend of their round to then cross

this mark (X) if the patient hadbeen bled and leaves the mark (/)if they had not been able to bleedthe patient. In this way doctorscould see at a glance whichpatients still required bleeding. Thesolution was introduced on bothpilot wards and was trialledsuccessfully for a number ofweeks.

• The Trust then introduced anelectronic patient/bedmanagement system (in real-time)which replaced the manualwhiteboard.

• A phlebotomy column was addedto the electronic whiteboard viewon the real-time system andinstead of a (X) being used thedoctors were asked to put an (R) inthe column for patients whorequired bleeding and thephlebotomists would then put a(B) for bled or (F) for fail inresponse at the end of their round.This was trialled for two weeks onone of the pilot wards and thenfeedback obtained. Feedback fromthe junior doctors stated that theirinput into the column was felt tobe a duplication of informationthey already had to hand on theirpaper patient lists but that thephlebotomists entry was extremelyuseful for them and did help toensure no outstanding bloodswere missed. The addition of adate in the entry was requested tohelp avoid any confusion forpatients having more than oneblood test over the course of theiradmission.

• The trial was adapted with onlythe phlebotomist enteringinformation as to which patientsthey had bled and rolled outacross both pilot wards.

West Middlesex University HospitalPhlebotomy column on real-time patientmanagement whiteboard

SIX.CASE STUDY

32

Measurable outcomesand impactCommunication between thephlebotomist and the doctors wasgreatly improved which benefitednot only the patients but also theworking relationship between thetwo staff groups.

Ideas tested which weresuccessfulThe idea of introducing a measure toimprove communication betweenthe doctors and the phlebotomyteam came from feedback given bythe junior doctors when the projectwas first initiated.

A process mapping session washeld involving all staff groupsinvolved in the phlebotomy pathwayi.e. junior doctors, nursing staff,phlebotomists and laboratory staff.This session helped to develop thesolution of introducing aphlebotomy column initially on themanual patient managementwhiteboard (and subsequently onthe electronic whiteboard in real-time).

The junior doctors entering whichpatients required bleeding into thephlebotomy column wasunsuccessful as it was felt by thedoctors to be a duplication ofinformation they already had tohand on their paper patient lists andinformation the phlebotomists alsoalready had (via the request forms)so was not seen to be beneficial.

How this improvementbenefits patientsThe benefit to the patients has comefrom ensuring that any outstandingbloods not taken by thephlebotomist are identified promptlyand addressed by the doctors ornursing staff on the ward. Thusminimizing delays to the patient’sbloods being tested and resultsbeing available to inform thepatient’s clinical management andpotential discharge.

How will this be sustained,potential for the future andadditional learningThis initiative has led to an improvedworking relationship between thedoctors and the phlebotomists andhas helped to improve the efficiencyof the phlebotomy pathway. This inturn has ensured that pathologyinformation is available to cliniciansto inform their decisions as early aspossible for all patients in the pilotwards.

ContactSian SuttonEmail: sian.sutton@wmuh.nhs.uk

In the last week, number ofdelayed discharges due to:

Communication Delay in bloodsbeing taken

Results notbeing back

Quality ofservice

Baseline

Follow-up

3.4

5.0

1.6

7.1

4.0

-3.1

6.8

4.3

-2.5

4.3

7.1

2.9Variance

Bothwards

Also reporting more bloods taken, fewer delayeddischarges due to waiting for results and overall asignificant improvement in services.

Doctorsreported improvedcommunication.

33

34

To establish if the time of a patient’sdischarge from hospital can beachieved earlier in the day by theirbloods being taken at 7 am on themorning of their estimated dischargeand the results returned prior to thedoctor’s ward round on the acutemedical unit.

Understanding the problemProject problem statement: Theaim of the project was to improvethe efficiency and flow of theinpatient phlebotomy pathway fromthe moment the request is madethrough to the result being viewed.By improving this we then hope toimpact on delays in results beingdelivered which in turn shouldreduce length of stay by allowingprompt and informed decisions to bemade with regards to patientdischarge.

Identification: From review of timespatient’s results were availablecompared to the timing of thedoctors’ ward round and followingfeedback from the junior doctors.

Data collection:• Number of patients with a same

day discharge who hadoutstanding blood test requests.

• Date/time of early morning bleed.• Date/time bloods logged on lab

system.• Date/time result reported.• Date/time patient discharged.

Analysis to be undertakencomparing results for patientsinvolved in the trial to other patientson the ward during the same periodand averages for previous months.

Waste: Patients waiting to go homesame day whose discharge isdelayed due to their results notbeing back in time for the doctors’ward round.

How the changes wereimplemented• Solution identified – The

phlebotomy early morning roundstarts at 8.00am, it was felt thatan earlier bleed was required toget the results back by the doctorsward round.

• Data was collected every twoweeks to identify how manypatients each day were due to bedischarged same day and also hadan outstanding blood request. Thiswas done to allow us to estimatethe size of the workload and thecapacity required to undertake itduring the trial.

• A daily sample size of two patientsper day was agreed with the leadnurse and matron for the ward.

Measurable outcomesand impact• The data seemed to suggest that

there were not that many patientsthat had a blood request, werescheduled for discharge, andactually went home. Only 10 ofthe trial sample of 48 patientswere discharged form the trialward on the same day, suggestingthat prioritising phlebotomy fordischarge may be difficult unless abetter indication of the patient’sposition on the discharge pathwaycan be given.

West Middlesex University HospitalEarly morning bleed

SEVEN.CASE STUDY

07/03/2011 9/04/2011

48

24

24

4

10

10

Trial Period

Number of sample patients reviewed as eligible togo home same day during trial.

Number of patients reviewed as eligible to gohome same day during trial but no blood requestform available for the early bleed or no bloodsrequired.

Number of patients bled early.

Number of patients bled early but not dischargedsame day.

Number of patients in trial bled early buttransferred rather than discharged.

Number of patients in trial bled early anddischarged same day

35

When looking at the patients thatwhere bled the number of datapoints where so few that any firmconclusions may be difficult to draw,but some further observations wereof interest.

• Despite similar bleed times thedischarge times were very variableregardless of when the report wasauthorised indicating other issueswere delaying discharge not thetiming of the blood results.

Ideas tested which weresuccessful• The night staff were able to bleed

those patients indicated asplanned for discharge enablingbloods to get to the lab quicker.

Ideas tested which wereunsuccessful• Ultimately the early bleeds did not

in this trial lead to significantlyquicker discharge.

How will this be sustained,potential for the future andadditional learningBased on the feedback form doctorsit was believed that earlier bleedsand test results would have apositive impact for patients. Thebenefit to the patients is that theirdischarge from hospital will not bedelayed waiting for pathology resultsand may mean that they can gohome earlier in the day. Howeverwhile the patients were able to bebled earlier the desired impact ondischarge was not evident and thistrial has raised some interestingquestions that require furtheranalysis and investigations:

• Why do so many doctors andnurses have the perception thatblood test results often delaydischarge?

• If this perception persists, can thisbe improved by a closer workingrelationship between ward staffand phlebotomy staff as indicatedin an earlier trial documented inthis publication (case study 5Dedicated ward phlebotomist).

• If blood tests do not delaydischarge, what is holding upearlier discharge and what can bedone to better align all the tasksthat need accomplishing to ensurepatients can leave earlier?

• Based on these results, it is notclear if sustaining early bleeds issuitable at the moment until moreis done to understand how thiscan lead to earlier discharges,which seem to include otherpatient pathways aligning toenable discharge.

ContactSian SuttonEmail: sian.sutton@wmuh.nhs.uk

On trial

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

Admission date/time

12/03/2011 17:39

31/03/2011 09:29

14/03/2011 15:15

15/03/2011 22:57

14/03/2011 21:23

16/03/2011 16:53

19/03/2011 07:42

31/03/2011 08:20

26/03/2011 21:14

04/04/2011 02:08

Date/time patient bled

13/03/2011 05:00

01/04/2011 06:00

16/03/2011 08:00

17/03/2011 06:00

16/03/2011 08:00

18/03/2011 07:00

21/03/2011 07:25

01/04/2011 06:00

30/03/2011 06:00

05/04/2011 06:30

Results authorised date/time

13/03/2011 07:55

01/04/2011 08:23

16/03/2011 10:24

17/03/2011 08:53

16/03/2011 10:12

18/03/2011 08:24

21/03/2011 10:28

01/04/2011 08:33

30/03/2011 10:03

05/04/2011 08:24

Discharge date/time

13/03/2011 16:19

01/04/2011 18:31

16/03/2011 17:23

17/03/2011 15:36

16/03/2011 13:22

18/03/2011 15:17

21/03/2011 13:00

01/04/2011 17:02

30/03/2011 13:18

05/04/2011 11:57

36

Availability of blood results by10.30 am from samples taken thatday have increased from less than15% to 100% of full blood count(FBC) and 70% of chemistry bloodresults.

Understanding the problemAll Warwick Hospital inpatient bloodresults (apart from intensive care) areat least 24 hours out of date whenreviewed on the consultant or juniordoctor rounds. This was a majorsafety issue. We created amultidisciplinary team of aconsultant, junior doctor, ward sister,phlebotomist, portering manager,lab receptionist and technicians tomap the process and understand themain delays in the in-patient bloodprocess. We discovered that theblood tests requested on the wardround on day one, were drawn bythe phlebotomists after 8 am on daytwo while the ward round washappening. The bloods weredelivered to the laboratory after theward rounds had ended. Theseinpatient blood samples hit the labjust as the outpatient and GPsamples were coming in, meaningthe results were not available untilthe late afternoon when the doctorswere no longer on the wards. As aconsequence, results were notreviewed until the following day’sward round on day three.

This also resulted in patients beinggiven inappropriate treatments: e.g.patient on anticoagulation therapywill be given inappropriate does ofanticoagulation, antibiotics(gentamicin, intravenous fluids andother drugs based on an out-of-dateresult.

The main delay is due to:• The phlebotomists rounds (9 am to

11.30 am) occurring while thedoctors are doing their rounds.

• The inpatient bloods samples aredelivered to the lab in a big batchjust as the GP practice andoutpatients samples are arriving inthe lab.

• The results are not processed untilthe afternoon when the doctorsare elsewhere.

How the changes wereimplemented• Night nurses ensure the blood

requests are where the patientsare (have patients moved wards?).

• Night nurses label the blood formswith bed, bay and barrier status toreduce the wasted time of thephlebotomists hunting forpatients.

• Phlebotomists start at 7.30 amand leave earlier in the day.

• The domiciliary phlebotomists jointhe inpatient or outpatientphlebotomists to keep the hospitalwork flowing to the lab in theearly morning before going out todo the domiciliary visits.

• Review of phlebotomists’ infectioncontrol technique: only glovesrequired, not gowns, for nonbarrier nursed patients, savingmoney and time between patients.

• Porters start at 7.45 am and followthe phlebotomists round thewards delivering small numbers tobloods samples to the lab.

• One lab technician starts at 8 amand processes the blood samplesas soon as they arrive.

Measurable outcomesand impact• From < 15% blood results back by

10.30 am on the day of request,to 100% of FBC and 70% ofchemistry blood results.

• Safer care: consultants andregistrars have now noticed thechange in the blood resultavailability: right care, on time,every time for inpatients.

• Predictable system; if a bloodresult is not back by 10.30 amthen the chances are that theblood sample is abnormal: this is awarning that the doctors mustphone the lab to check on sampleand review the patient atlunchtime.

• One day off the length of stay(LOS) for those patients where theblood result is the key todischarge.

• No increase in cost.

Warwick HospitalEarlier start for bleeding patients

EIGHT.CASE STUDY

37

Ideas tested which weresuccessfulMapping the process.Trialing the earlier start times for:• Phlebotomists.• Porters.• Laboratory staff to book in the

samples.

How this improvementbenefits patients• Potential for reduced length of

stay.• Safer care – Referring clinicians

have the right result in a timelymanner to give best possible care.

How will this be sustained/potential for the future/additional learningBenefits gained are now beingapplied to the emergency carepathway. All emergency diagnosticbloods for A&E and MedicalAssessment Unit are now deliveredby the air-tube with a 50 minute TATas the target. This allows for atarget of two hours from arrival athospital to a consultant plan fortreatment (which may includedischarge) for all emergencypatients.

ContactKate SilvesterEmail: kate.silvester@swft.nhs.uk

70

60

50

40

30

20

10

0

Day

ControlDayTues

8/6/10

ControlDayWed

9/6/11

ControlDay

Thurs10/6/12

PDSA 1Wed

16/6/11

PDSA 1Thurs

17/6/12

PDSA 2Mon

2/8/14

PDSA 2Tues

3/8/13

PDSA 2Wed

4/8/14

PDSA 2Thurs5/8/15

PDSA 2Fri

6/8/16

Sat7/8/17

Sun8/8/18

Nu

mb

ero

fre

sult

so

ut

9.00

to9.

59

Lab technicianoff sick.Technician notavailable until9am

Phlebotomists starts at7.30am. Two porters startat 7.45am to 9.45am.Lab technician startsat 8am

Weekend service

Plan Do, Study Act Cycles 1 and 2 (June and August 2010)Number of inpatient U&E results out 9am to 9.59am

120

100

80

60

40

20

08/9/10

12/9/1016/9/10

20/9/1024/9/10

28/9/102/10/10

6/10/1010/10/10

14/10/1018/10/10

22/10/1026/10/10

30/10/103/11/10

7/11/10

Perc

enta

ge

Day

% SFBC Release 1-.30

100%

Percentage of inpatient FCBs released by 10.30am - PDSA 3

120

100

80

60

40

20

08/9/10

12/9/1016/9/10 24/9/10 2/10/10

20/9/10 28/9/10 6/10/1010/10/10

14/10/1018/10/10

22/10/1026/11/10

Perc

enta

ge

Day

% U/E Release 10-.30

100%

Percentage of inpatient U&E released by 10.30am - PDSA 3

38

Russells Hall Hospital (Dudley)Faster return of specimens from acute ward

NINE.CASE STUDY

1.26

1.12

0.57

0.43

0.28

0.14

0Bone

Profile

Tim

eta

ken

CRP EGFR LiverProfile

RenalProfile

Full BloodCount

Main tests carried out

Before After

Average time taken from specimen collection to receipt in laboratory

Following observations of theprocess one area of delay in thesystem came from waiting totransport samples from wards backto the laboratory as a drop offsystem was in operation. Gettingsamples transported more frequentlymay enable samples to get to thelaboratory quicker and in smallerbatches, with anticipated potentialbenefits being faster turnaround ofblood results for acute ward anddelivery of specimens back to thelaboratory smoothed.

Understanding the problemProject problem statement: Thereis often a delay in getting bloodspecimens taken by the wardphlebotomists back to the laboratoryafter collection. Minimising this delaycould enable results to be availablemore quickly and potentially helptimely discharge; in addition wewanted to understand the broaderbenefits for the laboratory that maybe derived by smoothing the flow ofsamples received for analysis.

Identification: Ward A1 is anacute, short-stay ward where timelyreturn of results is essential to therapid discharge of patients. Therehad been instances where A1 hadnot had all their patients bled as theywere the last ward to be bled in theirgroup.

Data collection: Qualitative datawas collected via discussion with thesenior management, medicalrepresentatives and matron for wardA1. We also held a process mappingday with some of our phlebotomistswhich helped us understand theoverall process a little better.

Waste: Up to an hour or more couldelapse between the first specimenbeing taken and it appearing back inthe laboratory

How the changes wereimplemented• Solution identified: There had

already been discussion aboutchanging the order of the wardsso that A1 was bled first. This wasfirst trialed for two weeks toensure there was no adverse effecton the other wards.

• Additional resource was to beidentified to bring specimens backto the laboratory earlier and morefrequently, and to book thesespecimens in as soon as possible.This was to be trialled for two tothree weeks in the first instance.

Measurable outcomesand impactBringing the specimens back earlierand more regularly resulted in theaverage delay between specimencollection and receipt back in thelaboratory being reduced from overan hour to just 13 minutes for themain tests requested. The overalltime from specimen collection toresults being available reduced froman average of three and a half hoursto just over two hours.

39

Ideas tested which weresuccessful• The use of hospital volunteers to

bring the specimens back to thelaboratory.

• Getting samples back to thelaboratory sooner deliveredquicker results to the ward.

• Smaller batches in to thelaboratory smooths the flow,contributing to quicker turnaroundtimes, resulting in improvedmorale of the laboratory staff.

How this improvementbenefits patientsWhat became clear from the resultsis that while there are significantpatient benefits from the trial therewere also benefits for staff inparticular the laboratory staff.It should also be noted that thehospital volunteers also enjoyed theresponsibility of assisting withprocesses, making a significantcontribution to improving patientcare.

• Blood results are back with theward earlier in the day for decisionmaking.

• Earlier decision making haspotential to assist with earlierdischarge.

• Smoother flow and smallerbatches into the laboratorybenefited laboratory staff andflows of work.

4.19

3.50

3.21

2.52

2.24

1.55

1.26

0.57

0.28

0Bone

Profile

Tim

eta

ken

CRP EGFR LiverProfile

RenalProfile

Full BloodCount

Main tests carried out

Before After

Average time taken from specimen collection to results being available

How will this be sustained/potential for the future/additional learning• Continued use of hospital

volunteers is being explored forward A1.

• Further investigation into futureproofing this approach, canvolunteers remain or do we needa member of staff.

• The next step is to explore howresults back quicker can driveclinicians to make decisionssooner, and ultimately assist inspeeding up discharge.

• A questionnaire is being circulatedaround all wards to gain feedbackon the current phlebotomy serviceand when ward rounds take place.This information will be used tooptimise the time of return ofspecimens from all wards.

ContactJim YoungEmail: james.young@dgoh.nhs.uk

Contacts40

For further information on any aspects ofthis work please contact:

NHS Improvement Team

Lesley WrightDirectorlesley.wright@improvement.nhs.uk

Jamie BallochNational Improvement Leadjamie.balloch@improvement.nhs.uk

Peter GrayNational Improvement Leadpeter.gray@improvement.nhs.uk

Ian SnellingSenior Analystian.snelling@improvement.nhs.uk

Ana DeGouveiaDiagnostics Team PAanabela.degouveia@improvement.nhs.ukTelephone: 0116 222 5122

Victoria WardDiagnostics Team PAvictoria.ward@improvement.nhs.ukTelephone: 0116 222 5123

Contacts

41References

NHS Improvement – DiagnosticsPublications

Cytology improvement guide - achieving a 14day turnaround time in cytology (November2009).

Continuous improvement in cytology -sustaining and accelerating improvement(September2010)

Learning how to achieve a seven dayturnaround time in histopathology(November 2010).

Bringing Lean to Life (May 2010).

Department of Health

Equity and Excellence: Liberating the NHS(2010).

Report of the Review of NHS PathologyServices in England (August 2006).Chaired by Lord Carter of Coles(An Independent Review for the Department ofHealth)

Report of the Second Phase of the Reviewof NHS Pathology Services in England(December 2008).Chaired by Lord Carter of Coles(An Independent Review for the Department ofHealth)

Other References

Improving quality and safety by reducingSpecimen labelling errors (ASCP Layfield /Anderson)

References

Useful reading42

A3 Problem Solving for HealthcareCindy JimmersonISBN 978-1-56327-358-2Demonstrates how to use A3 to problemsolve. Contains practical examples fromUSA healthcare that can be easilytranslated to UK.

Lean Healthcare – Improving thepatient’s experienceDavid FillinghamISBN: 978 -1- 904235-56-9Written by CEO of Bolton NHS Trust as anaccount of his experience of the long termperspective of using Lean to supportwhole healthcare.

The Toyota WayJeffrey LikerISBN: 978-0071392310Explains Toyota’s unique approach to LeanManagement – the 14 principles thatdrive their quality and efficiency obsessedculture.

Creating a Lean CultureDavid MannISBN: 978-1-56327-322-3Helps Lean leaders succeed intransformation. A critical guide todeveloping and using a lean managementsystem.

The New Lean ToolboxJohn BichenoISBN: 0 954 -1-2441 3A guide to Lean tools and concepts

Useful reading

Learning to SeeMike Rother & John ShookISBN: 0-9667843-0-8An easy to read practical workbook forcreating a value stream map to evidencewaste in a process.

Managing to LearnJohn ShookISBN: 978-1-934109-20-5How A3 enables an organisation toidentify, frame, act and review progresson problems, projects and proposals.

Making Hospitals WorkMarc Baker and Ian Taylor with AlanMitchellA Lean action workbook from the LeanEnterprise Academy.

First break all the rulesMarcus Buckingham and Curt CoffmanWhat the worlds greatest managers dodifferently.

Value stream mapping for healthcaremade easyCindy JimmersonISBN: 978-1-4200-7852-7Demonstrates why value stream mapsare a fundamental component inapplying Lean.

43Acknowledgements

Our thanks go to all the pilot sites that have tested andimplemented changes and produced the case studiesfor others to benefit from.

Acknowledgements

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS ImprovementNHS Improvement has over 10 years improvement experience. With our practicalknowledge and ‘how to’ approach we help improve the quality and productivityof services through using innovative approaches as well as tried and testedimprovement methodology.

Over the last 12 months we have tested, implemented, sustained and spreadimprovements with over 250 sites to assist in improving services in cancer,diagnostics, heart, lung and stroke. Working closely with the Department ofHealth, trusts, clinical networks, other health organisations and charities wehave helped deliver key strategies and policies to improve the delivery andimplementation of improved services for clinical teams and their patientsacross the NHS.

Delivering tomorrow’simprovement agendafor the NHS

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NHSNHS Improvement

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