Thursday, November 06, 2008

Getting specimens to the lab

Not to overwhelm you, but this stuff is really exciting for our staff, and I hope you can understand why. I present another result from BIDMC SPIRIT, this one having to do with the collection of specimens. Can you think of anything more vital to how a hospital runs every day? Note that it was called out by a transporter, and see how this caused a varied group of people to work together. What better way to demonstrate our respect for each and every person working here?

This one took a while to fix because it was a pretty convoluted, complicated, and broken process.
For those reading this series of posts, please note, though, the repetition of key steps in the improvement process. Part of what is going on here is that staff members at multiple levels in the hospital are learning a consistent way to address process improvement. Thus, the organization as whole grows while individual problem areas are solved.

Where did we start?

On 5/13/08, callout made by transporter regarding amount of time spent and uncertainty re: value added reconciling GI specimens.

After discussion among staff from all departments involved (including front line staff, managers and Sr. VPs), the group determined that the entire process of tracking and transporting specimens from the procedure room to the lab (not just transporter specimen sign-out) offered multiple opportunities for process improvement:

Problems identified included:

§ Location of the specimen tray was far from the procedure rooms;

§ It was deemed unnecessarily time consuming for every individual specimen to be “signed out” by a transporter and not clear that it added safety;

§ There wasn’t an opportunity built into the system for the GI physician to interact with the GI nursing staff so that information could be compared on the specimen requisition and the specimen jar label;

§ Paperwork to accompany specimen was not always completed in a timely and uniform manner;

§ Confusion about transport pick-up times;

§ No reconciliation taking place when specimens arrived in Pathology and no immediate feedback to GI of missing specimens;

§ Time and “peaks and valleys” of volume of specimens delivered to pathology caused operational challenges for pathology;

§ Not all steps were defined and standardized;

§ Process resulted in delays;

§ Opportunities for staff time in all 3 areas to be more productive and satisfied;

§ # and process for hand-offs created opportunities to lose specimens;

§ Frustration/tension among departments (GI, transport, Pathology);

§ Project was good one to provide opportunity for many BIDMC staff to apply Lean/SPIRIT principles.

What process did we use to design new process?

1. Front line staff and managers from each area described current practice and problems.

2. Included GI physician in design process.

3. Drew process flow for entire current process, listing all problems/potential for errors.

4. Group described “ideal” state (using “Lean” principles described below). New process flow drawn.

5. Entire group developed specific steps for each activity in process, understanding each others’ roles.

6. Tweaked process flow as specifics required.

7. Challenged any step that was inconsistent with “design principles” to get closer to “ideal”.

8. Rolled out new process; called out outstanding issues – continued to tweak process; managers shadowed staff; process improved continuously when problems arose.

9. Deemed successful and ready to be “spread” to other procedural areas.

“Lean” principles used to shape “Ideal” new process

“Activity” Principle: Specify all steps in process;

“Connection” Principle: Ensure communication and hand-offs can be carried out appropriately;

“Pathway” Principle: Include no (or minimum) “forks” or “loops”, i.e., each member of the team should have one clear path to follow;

“Improvement” Principle: Use scientific method (data driven, evidence based, willingness to experiment), involve front line staff, keep improving -- “call out” when unable to perform step as specified.

Major Elements of New GI Specimen Tracking/Transport Process

-- Specimen tracking book moved to more convenient central location in GI, reducing delays and distance staff need to walk.

-- Binary connections between staff members: Procedure RN and MD interact directly (when possible) with resource nurse at time of dropping off specimen and req so discrepancies can be discovered and remedied at time of hand-off.

-- Consolidation of responsibility: One resource nurse designated to “tag” all specimens. As a result, process occurs in more timely fashion and specimens are delivered more uniformly to pathology.

-- Modification of Sign-Out Sheet: Transporter no longer has to sign out each individual specimen by patient name.

-- Each patient’s specimen placed in single clear bag (easy for nurse to count/identify).

-- Each patient bag placed in large disposable clear bag with single letter designation eliminating need for Transport to return to GI in between and bags to be tracked to Pathology.

-- Completion of reconciliation process in Pathology.

-- Rounds occur more frequently/consistently which GI can count on and delivers more consistent number of specimens to be delivered to Pathology (did not require adding resources as transporter time freed up by not having to complete individual test reconciliation as noted below).

-- Log created so Transport could indicate what time they arrived/which lettered bag they dropped up. This also includes a column for Pathology to indicate # number of specimens that were actually in the bag.

Bottom Line

-- A reduction of 57% in the amount of time between when a specimen was ready for transport and when transport arrived to pick the specimen up.

-- A reduction of 61% in the time it took to transport specimens to Pathology.

-- Freeing up of hours of transport time/day without sacrificing the safety associated with this task.

-- Much improved workflow for the pathology techs.

-- Improved communication between nursing and physician staff, further reducing instances of mismatched information between the specimen label and requisition.

What does this mean to BIDMC?

Reduction in time-wasted activities by staff
Clarity in role responsibilities re: specimen tracking
Consistent and standard process from point specimen is taken to point specimen is received in pathology
Improved Patient Care/Safety Controls + Improved Employee Satisfaction and Collaboration + Better Use of Resources

Next Steps

Spread this standardized process (with refinements as needed given the specific operations and physical layout of each department) to all departments in the medical center that collect and send tissue specimens bound for the department of Pathology.


Anonymous said...

Take my yesterday's comment: repeat. (:
Another routine, but sometimes overlooked, facet of this process improvement is to ensure that all policies, procedure manuals and new employee training materials in all affected depts are revised to reflect the new process - so that it survives its creators when they move on. I am sure you have this covered, but sometimes this last paperwork step is not completed.
Great work! Perhaps only we "process wonks" enjoy reading this stuff, but it really does make a difference to patient care!


Anonymous said...

Many thanks (again!)

Anonymous said...

It is an illuminating commentary on the management of our health care delivery system (or, more precisely, the lack thereof) that it has taken until late 2008 for somebody to take this on. The convoluted, cumbersome, unreliable and expensive system you describe has been growing like Topsy for goodness knows how long without anybody paying any attention until a lowly transporter blew the whistle.

Let us recognize that introducing management into health care is one of the important things that health care reform ought to be about.

Richard Wittrup

Anonymous said...

It has been great to be part of the team that developed and rolled out this new process. It's worth mentioning the wonderful folks who embraced the opportunity to redesign in this new way. They came together open to change, really listened to how the work of each affected the other, and together came up with a process that is better for all involved AND improves safety.

It's worth listing their names and their various departments and job categories: Transport Dep't (Nebiye Woldehaimanot, Mgr; Gloria Martinez, Transporter); GI (Julie Doherty, RN; Christine Hunt, RN; Dan Leffler, MD; Janet Lewis, Mgr); Pathology (Judy Jensen, Dir; Gina McCormack, Dir; Donna Fayad, Mgr; Gail Howe, Supervisor); Administration (Jayne Sheehan, Sr. VP; Eva Greenwood, Dir, Ops; Davin Janicki, Project Mgr, Health Care Quality; Jason Monarch, Value Capture consultant). And after successfully rolling out this process in GI, many on this team have been leaders in spreading the lessons and specific to other departments. In fact, at a meeting yesterday with all the other procedural areas, there was agreement to roll this out as the standard pathology specimen process in all units by December 1.

Thanks to you, Paul, for your leadership and support in this new way of solving problems. I really believe it leads to better workflow, more satisfied employees and perhaps most importantly in a complicated organization like a hospital respect and collaboration among departments and between managers and front line staff.

-Joanne Marqusee, Sr. VP, Operations, BIDMC

Anonymous said...

Was on a search for hospitals using social media for a presentation next week and came across your blog.

I am so impressed by your blog and the total transparency of this process as outlined in this post for your readers. The nitty gritty might be especially interesting for "process wonks," but from a communications perspective it's this kind of transparency and authenticity that is crucial for this medium. You're engaging stakeholders, listening and responding to critics and, ultimately, building relationships.

I'll be bookmarking this post a great example of how this can be done right. Thank you!

- Kelli

Anonymous said...

What a great result! It is really incredible to see that you were able to re-engineer the process for dramatic improvement.

What many onlookers don't realize that the core function of all the stakeholders and players (departmet heads and staff) is to take care of the patients at your hospital---that is job #1. So, when they can get together on a special project like this out of their ever increasing busier schedules to make positive change happen then this is really a GREAT PROJECT RESULT!

I am curious though, how do you promote this internally to your staff, sometimes I feel that staff does not get enough credit and recognition on participation in these special projects?

Newsletters? Dedicated Bulletin Boards in common areas? Award Luncheons? How?


Anonymous said...

I am responding to an old post regarding a process improvement at BIDMC, which interested me since I work at a hospital.

I could not help but be offended by Richard Wittrup's language choice of a, "lowly transporter" who blew the whistle.

What is lowly about this transporter, or any transporter, for that matter? Every team member is important. Let's take care to use respect in our language and how we view our colleagues. And clearly, this woman who won the "call out award" is anything but lowly!

November 06, 2008 7:53 AM
Anonymous said...
It is an illuminating commentary on the management of our health care delivery system (or, more precisely, the lack thereof) that it has taken until late 2008 for somebody to take this on. The convoluted, cumbersome, unreliable and expensive system you describe has been growing like Topsy for goodness knows how long without anybody paying any attention until a lowly transporter blew the whistle.

Let us recognize that introducing management into health care is one of the important things that health care reform ought to be about.

Richard Wittrup

November 06, 2008 12:51 PM

Anonymous said...

I totally agree!