Wednesday, November 05, 2008

Fixing bad blood tests

Here's another example of process improvement that typifies BIDMC SPIRIT, with remarkable success resulting from application of Lean principles, applied with advice from our small, but able, Business Transformation group. I supply an edited version of the narrative given to me:

What do you get when you cross well intentioned Emergency Department (ED) Nurses (RNs) with fastidious laboratory technologists? You get a problem, an opportunity, and a bevy of talented professionals poised to collaborate on a mutual solution.

Why would ED RNs do anything that might delay treatment? Why would a lab technologist take an extra 56 minutes to provide a potassium test result? Why…because each role cares deeply about the patient; but in divergent ways. This divergence spoke to us. We had two groups not understanding the impact they had on each other, and combined, their impact on patient care.

As this scenario shows, many patients cross multiple departments and value streams as they receive care. The departments knew that quality was a problem but wanted to benchmark how they stood in relation to the rest of the hospital. One measure of quality in the ED is the hemolysis rate (the rate of defect specimens that skew a patient’s laboratory test results). Data was collected by the ED nurses and laboratory technologists and was then presented in a rapid improvement event to uncover the root cause of the quality problem.

The hemolysis rate for lab specimens collected in the ED was found to be 22.4%, approximately five times their counterparts on the inpatient units (3.9%). This rate had several deleterious effects: patient’s hemolyzed specimens often had to be recollected and retested, therefore these patients had to wait on average 56 minutes longer for lab results, and frustration levels in both the ED and the laboratory were high.

As we knew, hemolysis is a byproduct of improper specimen collection and has an unintended effect on lab results. The effects on results can be can be minor, moderate, or actually cause inaccurate and incorrect results. One test in particular, potassium, is significantly impacted by hemolysis. It is a very significant test for heart patients where small changes can be noteworthy. We saw an opportunity to examine practice, past studies, and identify opportunities for improvement. A decreased hemolysis rate would result in improved ED throughput, reduced length of stay for the patient, fewer recollections (savings in both time and materials), and better patient satisfaction.

To address the high rate of hemolysis in the ED, two in-depth studies were completed. The first was to obtain the hemolysis rates for collections via an IV insertion versus a peripheral blood draw (venipuncture). The second study focused on hemolysis for specimens drawn through the IV using one of three methods: Vacutainer, extension tubing, or syringe. The data indicated that specimens collected during IV insertion showed a much higher rate of hemolysis, especially when using a vacutainer (the ED’s current preferred method).

We also assembled other hospital experts. The phlebotomy manager and a venous access nurse came to our event to observe, comment, and critique our ED nurses and ED techs as they simulated current practices (on a dummy arm). Each of us learned a lot and took note of areas in the process where we noticed a lack of standardization. We were most struck by the variability of practice, not only staff in the ED but of staff around the medical center. Thus, we had a great opportunity to standardize and create best practice for the medical center. A mistake-proof, proper technique is the key to preventing hemolysis.

Our goals were simple: develop a standardized method of drawing labs in the ED by engaging the ED and lab staff who do the work and strive for the common goal of reducing the hemolysis rate by over 18%. This would generate a cost and time savings as a result of fewer patient re-sticks, fewer repeat tests, improved quality due to better sample integrity, and potentially contribute to higher patient and staff satisfaction.

Our intent was not to place blame but rather to really understand the root of the problem. We gathered data from other areas of the hospital which also collected specimens during an IV insertion. Each area reported no problems with hemolysis, but our investigation uncovered they did, in fact, have a problem. None of the tests they ordered were impacted by hemolysis; so these groups were unintentionally blind to the problem. But this showed us that the individual technique of the person collecting the specimens although variable, is less of the root cause.

As we talked about hemolysis, we broadened our outlook and realized how complicated this is to operations. Due to the unpredictable patient flow, changing clinical needs of each patient, and variability of each RN, ED Tech and MD practice-styles, this was a very complex process to define. But we were committed to finding a solution. Each area owned this problem and for various reasons wanted to find a solution. The lab would have fewer critical values to repeat, call, and document. The ED would have fewer patients to re-stick, faster results, and happier patients.

During our time working on this issue we learned and communicated the following to the respective Lab, and ED staff:

• Long tourniquet time (>1 minute) increases Hemolysis
• IV product manufacturer does not support blood draws from IV equipment.
• Medical center IV and Phlebotomy Experts do not teach or recommend IV Draws
• Most ED staff worried about sticking the patient twice (once to set-up an IV and again to draw blood through venipuncture) - creating a negative experience for the patient. However, almost 30% of the time they did stick people twice due to Hemolysis which created a 56 minute delay.

We embarked on a pilot project after the event. Our intent was to stop collecting blood specimens at the time of IV insertion. To accomplish that goal, the ED techs (who only can draw via venipuncture) would draw all of the blood. Prior to the implementation, our phlebotomy team retrained the ED techs according to the Pathology venipuncture standards. Once this process was in full swing, the plan was to review all specimens from the ED and check the tubes for hemolysis and feedback the data to all of the parties on a daily basis. Each day the lab reviews over 100 specimens collected from the ED needing potassium results. We post the daily hemolysis rates and investigate each hemolyzed specimen with the RN caring for the patient. The average hemolysis rate over the past few weeks is now averaging 6.5%. As of this past Monday, this trial becomes the official way we draw blood in the ED.

We realized these incredible results by walking in each other’s shoes, touring each other’s areas, and understanding impacts by using data. We talked to each other and brainstormed together and cooperatively moved forward. Lab staff now attend the ED huddles so continued learning and sharing can take place; even after we solve the hemolysis problem.

In the end, it was our collective actions, willingness to put departmental issues aside, strong desire to improve the patient experience, and ultimate respect for each other’s talents and expertise that propelled our project forward.

Name, Role, Title
Gina McCormack, Pathology Admin, Operations Director
Kirsten Boyd, ED Director, Director of ED
Larry Mottley, ED MD, Quality MD
Jane Dufresne, ED CA, Clinical Advisor ED
Steve Wood, ED RN, RN Staff ED
Tammy Galloway, Chemistry, MGN Chem
Manny Alves, Lab West, Lab Supervisor
Blanche Murphy, Venous Access Nurse, RN Staff ED
Susie Fontes, ED RN, RN Staff ED
Pam Hulme, Phlebotomy, Customer Service manager
Kellie Glynn, ED RN, RN Staff ED
Christine Yennaco, ED Tech, Staff Tech ED
Brian Orsatti, ED Tech Supervisor, Tech Supervisor
Alice Lee, Lean, Office of the President
Kimberly Eng, Lean, Office of the President
Brandan Holbrook, Lean, Office of the President
Bonnie Baker, Lean, Office of the President


Anonymous said...

Very impressive. How long did this whole process take?

Anonymous said...

Boy, every sentence of that was familiar. The beauty of Spirit is in providing the structure in which to solve it, instead of trying for months to get the ER to pay attention to the problem, as happened in our shop. (:
However, there are two lessons from your story:
a) the real challenge will be to maintain this improvement thru months and years, as staff and leadership change and pretty soon no one remembers how or why this came about. At that point, hypothetically, they will have a reason (related to some other issue) why the nurses and not the ER techs should draw blood, and you will have to repeat the whole thing. I put this forth as a risk, not an inevitability; and it applies to the whole Spirit program.

b. our hospital went through the exact same process of discovery about drawing through IV's, etc. and came up with roughly the same solutions. Once again, this points up the need for some sort of national clearinghouse to prevent reinvention of the wheel. As healthcare comes under more and more pressure to operate more efficiently and cost-effectively, institutions will have less time and money to individually go through these extensive processes.

nonlocal (former lab med director)

Anonymous said...

The multidisciplinary team got together for 2 days after running the 2 studies as Paul outlined. Much of the work described in the blog was done in these 2 days (including observations of current techniques, data collection & analyses, bringing in subject matter experts, mapping out the blood drawing process in context with the bigger ED patient experience).

The group agreed at the end of these 2 days to trial a new blood drawing process. The pilot ran for the month of October where we measured the hemolysis rate daily and posted it both in the ED and the Lab, huddled together daily, looked at every instance of hemolysis to see what was the cause and shared all of the findings with both ED and Lab teams. This approach was instrumental in the change management process. We continue to measure and post even though this is our new current state process as of this past Monday.

Having the people who do the work involved from the begining is key. It was equally important to have 2 great team leaders from the ED and Lab open to change and supporting the team throughout this journey.

Anonymous said...


I got your message, and I would like details. Can you please mail them to me?


Anonymous said...

The process was good. The need for regular review and the risk of having to re-learn from time to time is evident from the fact that the root causes of hemolysis have been published for some time.

Anonymous said...

Thanks so much. This was a great team effort and perhaps the connections and relationships we made in the process were more important than the results! We built a lot of equity with each other.

Anonymous said...

to Anonymous (former lab director)& Anonymous 1144pm:
In fact, the ED RNs are still drawing many of the blood samples. They find it works within their workflow so the graph above represents that workflow.

As for the root cause of hemolysis having been published for some time - yes, we were aware. This was really a change management effort and it was important to bring the ED and Lab together to truly understand cause and effect and impact on patients. The 56 minutes extra on average a patient waits for a result with a hemolysed specimen was eye opening. Reviewing over 250 patient satisfaction verbatims and sharing with the team that not a single comment was about being stuck twice with a needle but many comments on waiting gave a different perspective. Bottom line, everyone wants to do a great job and what is best for the patient.

In any case, one of the pillars of Lean is continuous improvement. We continue to measure and share the data with the staff. Every instance of an IV draw is documented in the ED QA log with reason so we can continue to learn. The other pillar of Lean is Respect for people. That is what this truly was about. Thank you.

Anonymous said...


Thank you for your comment, and it is true that there is nothing like seeing the problem with one's own eyes in order to obtain buy-in from all involved staff. However, my comment about having the ER nurses draw was meant to illustrate a larger point - that sometime way down the line, there will be another, related ER-lab process that needs changing, and if all staff have turned over by then, there will be no institutional memory to reinforce the reasoning behind your current process to avoid hemolysis. Thus, there is risk that the
current process would then be changed to meet another need and, as a side effect, reintroduce the hemolysis problem.(I hope you can understand what I am trying to say - one of the deficits of written communication!) Sometimes this regression is not apparent except to those of us who have spent a long time in one hospital.


Anonymous said...

Anonymous 7:26am,
Thank you for the clarification. Our goal as a team is to instill understanding of how one's work can be continuously improved with the patient in mind - changing how employees see their work in context of a bigger system. The institutional memory focus is having staff 'see' what wastes are present in any of the processes and how can we design processes to eliminate them and a bit less on the particular point solution. Does that make sense?

For example, this morning I heard about Jose, a par stocker, who brought up a box of needles for flu shots to an inpatient unit who has had their supply room transformed with 5S and visual management to reduce overstocking, searching and stock running out. He noted to the nurse manager that the allotted space for these flu needles could cause confusion and maybe even errors since the flu needle box looks nearly identical to the other needle box next to it. They agreed and found a different spot and clearly labeled both. Jose sees his work differently now. He is a partner with the unit in ensuring our patients are as safe as they can be.

This is exactly what we strive for - a workforce who respect each other and work together to solve problems daily, to make it as safe as possible for our patients and staff. Thank you.

Anonymous said...

Thank you Paul for sharing this - it is great work and we are all very happy to see the process / changes make a positive impact for the ED and our patients. The Staff of the ED and the Lab have done a wonderful job in working towards a common goal - excellent patient care. Kirsten

Anonymous said...


At the risk of belaboring the discussion, I entirely agree with you and, as Paul will attest, have been very impressed with BIDMC's efforts to empower front line employees. This is truly what it's all about in a work environment like a hospital - similar to no other, in my opinion. The importance of this attitude cannot be overstated.
I, however, speak from the viewpoint of a veteran of many process improvement programs at my hospital system over 20 years, and of a "life sentence" on the medical executive committee as chair of a hospital-based department. I am simply noting that process improvements, over time, tend to regress back to the mean - so that we long-timers would hear the same "process improvements" over and over as improvements were somehow un-improved by new staff, or fell by the wayside some way or another. (Sometimes we would say, gee, didn't we already do that 5 years ago?) So think about the work you are doing now from a viewpoint of 5-10 years from now - you may have moved on, but are all your processes still improving and have the improvements you have made been lasting ones? That is all I am trying to say - and i think I better quit now before I wear out my welcome! (:


Anonymous said...

Funny, I am a Health Administration Master's student at the University of Alabama at Birmingham, and was assigned a project at the beginning of the semester almost verbatim what you have just described. Impressive work and thanks for blogging it, now I have some more material to cite and benchmark against.