Paean to Process

By Kathleen Waton, Associate Editor

Process improvement techniques come and go—or at least the names of the programs change. A consultant comes in, tosses around some jargon, demonstrates ideas that are common sense and soon everyone is chanting the slogan du jour. Lab services personnel at Jackson-Madison County General Hospital wanted to improve processes in their lab. Reduce steps, eliminate waste and make patient care goof-proof became their mantra. But they didn’t just pay lip service to process improvement. They took it to heart and translated common sense into common practice. The results they achieved in time savings, efficiency gains and reduced errors illustrate the triumph of process for labs—and beyond.

Lab services at Jackson-Madison took a three-step approach over the last few years. They streamlined their work processes, moved into larger, more efficient facilities and, most recently, added an automated patient identification system.

Jackson-General, a nonprofit 662-bed tertiary care hospital, is the flagship of West Tennessee Healthcare (WTH). Located between Memphis and Nashville, the system has 4,000 employees. Jackson-General is the largest hospital in the system, which includes six hospitals, home healthcare agencies and outpatient rehabilitation facilities. The lab has more than 190 employees including 48 phlebotomists. It billed 1.25 million tests in 2005.

Streamlined Workflow
Jackson-General began lab automation in the late 1980s, with the introduction of a MEDITECH lab information system (LIS). Over the years, they added sophisticated automated analyzers with a robotic track system to deliver specimens to the instruments for analysis. But even with automation, they were unable to achieve the turnaround time they wanted to collect specimens and receive them in the lab.

In 2003, phlebotomists carted as many as 30 LIS-generated labels up to the patient floors, drew blood, labeled the samples and then escorted the samples down, in large batches, to the main lab on the hospital’s ground floor. This labor-intensive process carried numerous opportunities for errors, including mislabeling samples and missed collections. The result could mean having to recollect samples and inconvenience patients.

In March 2003, Jackson-General introduced Ortho-Clinical Diagnostics’ ValuMetrix process improvement program of lean management to revamp their entire lab. They started with the phlebotomy process and specimen collection. Lean management is the “process of identifying all aspects of waste within a system and getting the work where it will flow in a single piece,” says Jamie Boone, assistant director of laboratory services.

Lab services applied lean management principles to their existing specimen collection process, reducing the juggling of many labels to handling a single label at one time. Phlebotomists now retrieved an individual label from a holding area on a patient floor, drew the blood, labeled the specimen and sent the specimens one-by-one through a pneumatic tube to the lab. “This reduced the number of labels the phlebotomists handled at one time and the mixing up of samples,” says Boone. It also avoided inundating the lab with batches of samples. Streamlining the process improved the collect-to-receive time from an average of 21 minutes to an average of 6.5 minutes—a phenomenal 70 percent improvement.

New Lab Facilities
In the fall of 2003, Jackson-General began a three-year building renovation project and constructing a new patient tower. In September 2004, lab services relinquished its space on the first floor of the hospital to outpatient departments and moved across the street into a new 40,000-square foot building dedicated completely to the new Medical Center Lab. Lean management principles drove the design of the lab—from supply handling to the testing areas.

“We were connected by an extension on an existing underground tunnel,” Boone says, “but because we were further away from the hospital, we needed to be more efficient to meet our turnaround time.” Lab dispatch supervisors spent too much time processing lab work. Phlebotomists also still had too much “nonvalue-added hands-on time,” Boone says, and they needed to make sure they identified the patient properly.

Boone teamed up with the phlebotomist manager, the LIS assistant director and the executive director of the lab to find an efficient and effective patient ID system. The patient identification project team zeroed in on BD Diagnostics because the Franklin Lakes, N.J.-based company supplied the lab’s vacutainers. The team considered a couple of other companies, Boone says, and obtained management’s and nursing’s input. “We were partial to BD’s system, however, because of their price and quality,” she says and also because of BD’s history of interfacing effectively with their LIS. The BD system allows nursing as well as lab staff to monitor collections from any PC, reducing phone calls to verify a test has been ordered. The phlebotomy supervisor can see the total picture on one screen of all orders and know where phlebotomists should be.

Assurance of Positive Patient ID
In March 2005, the patient ID project team chose the BD.id patient identification system for specimen management. They bought 15 pocket PCs, docking stations and small battery-operated printers. Today, specimen collection is complete and accurate in several easy steps.

When the nurse or unit secretary enters a specimen collection order into the hospital’s LIS, the order is downloaded to the BD.id server. The server transmits the order to a pocket PC that contains a bar-code scanner. The phlebotomist scans his or her identification badge first and then scans the patient’s bar-coded wristband to verify the patient’s identity. The printer produces a specimen label at the bedside. The label lists the phlebotomist who collected the sample, as well as the patient, the date and time of the collection, the container type and the test ordered. Once the phlebotomist draws the blood and labels the tube, she whisks her collection off to the lab via the pneumatic tube at the nurses’ station. The pocket PC uploads the collection information to the LIS via a docking station, indicating that the sample is on its way to the lab to test.

“The system assures us that the phlebotomist is in the right place with the right patient and collecting the right test in the right tube,” says Boone.

BD Diagnostics and MEDITECH IT staff spent the summer of 2005 primarily fine-tuning the interface between the lab information system and the new patient ID system. “We didn’t have to wait until all the interface issues were worked out to start learning the system,” Boone says. Lab personnel “played” in the lab dispatch room with the pocket PC, simulating different scenarios of collecting specimens. Staff were proficient within two hours and Jackson-General went live with the new patient identification system on September 26, 2005.

More Real Time Processing
Today, specimen collection at Jackson-General is more real-time, according to Boone. Before the BD.id patient identification system, phlebotomists had to wait for the lab dispatch supervisor to print their lab orders and shuttle them via the pneumatic tube to the patient floors. Now phlebotomists coming on shift pick up a pocket PC from the nurses’ station on each floor and immediately see their orders. The screen on the pocket PC indicates “STAT,” “Urgent” or “Routine” with a letter. If an order becomes overdue, the status changes color. Phlebotomists have more control over their work and there have been no instances of misidentified patients since go-live.

With the new patient identification system, Jackson-General anticipates reducing the 30- or 40-minute order-to-collect time to 20 minutes. They expect their 8.4 percent wrong container rejection rate to fall to 2.0 percent, in line with other peer group standards. Boone and others envision the 42 minutes lab staff spend daily, on average, wrestling with specimen recollects or resolving other lab issues to drop 50 percent. They also hope to see actual errors fall from an already low 0.6 errors per month to zero.

Wireless and Paperless
Phlebotomists share the pocket PCs among the various patient floors. The goal is, however, to roll out the patient identification system on every floor at Jackson-General and to several hundred nurses in high volume collection areas such as labor and delivery, oncology and ED. In two years, Jackson-General plans to go wireless and 95 percent paperless. Jackson-General’s current patient ID system has wireless capabilities, so swapping their wired system for a wireless system will save the phlebotomists even more time. Phlebotomists will only use the docking stations to charge the pocket PC’s battery. They won’t have to upload data from the pocket PCs at the docking stations.

An automated patient identification system is one more step for Jackson-General in their march toward being a paperless hospital. One small step for lab services. One giant step for this rural hospital and its patients.

For more information on BD Diagnostics’ BD.id patient identification system,
www.rsleads.com/603ht-201