But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Thursday, November 6, 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.

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