Phlebotomy and Delayed Discharges at an Academic - Teaching Hospital

Phlebotomy & Delayed Discharges at an Academic Teaching Hospital Hospital Overview • Academic Teaching Hospital – Residents make the clinical decisions – Attending physicians supervise & teach • Hospitalized Patients – Clinical decisions Å Information from laboratory tests on blood samples • Drawn multiple times daily (usually scheduled) – Census: 150-180 medicine & surgery patients No change Current Level ov pr Im t en em Elapsed Time from Order until Results Available Problem Statement “Acceptable” Minimum Perfect World 1993 2004 2005 Average Turnaround Time for Lab Test Results 1. Inefficiency – Impedes clinical decision-making 2. Lower Quality & Higher Risk – Delays patient care plan implementation 3. Lower Margins – Increases chance of postponed discharges Work Context • Two interdependent “organizations” – Laboratory & Phlebotomy (operations) – Physicians & Nurses (clinical) • Constraints affect each group differently – No one group sees entire system – Nobody looking out for entire system • Groups blame other groups, not system Challenge: Getting Everyone Around the Same Table • How did we meet this challenge? – Required tactful facilitation of entire team – Active listening Æ elicit frustrations – Use “objective” process flowcharts • Build understanding of how things work • Basis for communication among groups My Insights Client Insights • Results – “I had never heard that lab turnaround time delayed clinical decision making.” – VP, General Services – Residents and nurses blame phlebotomy for being unresponsive Æ don’t realize they are understaffed – Residents don’t realize they make an implicit risk tradeoff: act without info or wait for info Æ patient safety Client Insights from Reference Modes • System in Equilibrium – Patient volume consistently close to maximum capacity – Staffing levels “frozen” because of chronic budget shortfalls – Phlebotomy productivity is stable and better than the benchmark • Dissatisfaction with Lab Turnaround Time Æ “paradigm shift”, not erosion of current service Putting the Pieces Together Quality of Patient Care R Average Time to Make Clinical Decisions Quality Erosion + + Average Length of Stay Average Lab Turnaround Time R - Death Spiral - Phlebotomists + Hiring + Hospital + Profit Putting the Pieces Together Quality of Patient Care Clinical Organization R Average Time to Make Clinical Decisions Quality Erosion + + Average Length of Stay Average Lab Turnaround Time R - Death Spiral - Phlebotomists + Operations Organization Hiring + Hospital + Profit Phlebotomy Staffing Policies (1) • Insight 1: Hospital financials constrain ability to hire phlebotomists – Can’t close staffing gap Quality of Patient Care R Average Time to Make Clinical Decisions + Quality Erosion + Average Length of Stay Average Lab Turnaround Time R - Death Spiral Phlebotomists + - B Staffing Gap Workforce Adjustment Hiring + + Hospital + Profit • Insight 2: Little attention to phlebotomy supplydemand balance across depts Policy Implications • Need proactive, periodic review of where phlebotomists are assigned Phlebotomy Staffing Policies (2) Quality of Patient Care - • Insight 3: Lower profitability results in fewer desired staff – Should phlebotomy be cut in a budget crunch? – What staffing level is “optimal”? R Average Time to Make Clinical Decisions Quality Erosion + + Average Length of Stay Average Lab Turnaround Time R - Death Spiral Phlebotomists + - B Workforce Adjustment Staffing Gap + Hiring + Hospital + Profit + R Positions from Budget ? Desired Phlebotomists Policy Implications • Need proactive, periodic review of where phlebotomists are assigned • Investments required to get out of the hole – Possibility: Hire more phlebotomists when profitability is low No Silver Bullet Quality of Patient Care ResidentDrawn Labs R + Average Time to Make Clinical Decisions Quality Erosion + B Make Up Shortfall + Average Length of Stay Average Lab Turnaround Time - R Death Spiral Phlebotomists + - B Workforce Adjustment Staffing Gap + Hiring + Hospital + Profit + R Positions from Budget + Desired Phlebotomists • Residents make up phlebotomy staffing shortfall No Silver Bullet Quality of Patient Care ResidentDrawn Labs - R Fix that Fails + + Average Time to Make Clinical Decisions R Quality Erosion + B Make Up Shortfall + Average Length of Stay Average Lab Turnaround Time - R Death Spiral Phlebotomists + - B Workforce Adjustment Staffing Gap + Hiring + Hospital + Profit + R Positions from Budget + Desired Phlebotomists • Insight 4: Residents as “solution” makes problem worse – where to allocate time – time to make clinical decisions is most important • Insight 5: Shorter lab turnaround time is necessary, but not sufficient, for better performance Policy Implications • Need proactive, periodic review of where phlebotomists are assigned • Investments required to get out of the hole – Possibility: Hire more phlebotomists when profitability is low • Focus on improving timeliness of clinical decision-making and interventions – Pay special attention this high-leverage point – Don’t just fight fires when crises happen – Hard to measure abstract processes Client-Reported Project Benefits • Explore system response to changes – Justify incremental phlebotomy staffing – Time required to make clinical decisions is the high-leverage point • Info available earlier must be acted on earlier • more process improvements needed • Insights not possible from discussion alone – Everyone tends to focus on the details of their area Æ need framework for systems thinking – Recognize that processes evolve around constraints (e.g. when rounds happen)