Laboratories are constantly seeking to improve their services for the benefit of their patients, but are usually under significant budgetary constraints. Sometimes all that is required to improve patient safety is a little creativity and ingenuity. What follows is a real life case study, with the details changed, highlighting the innovative minds of medical laboratory scientists and their counterparts on the patient-centered care team.

Lincoln Cardiac Health (LCH) is a hospital in the Midwest specializing in outpatient cardiac care. LCH has a reference laboratory, called Lincoln Premier Diagnostics Labs, on its campus that also serves external clients. This lab is where all of the laboratory testing ordered by LCH providers is performed, save a few esoteric sendout tests. The reference laboratory has multiple sections spread across its expansive campus due to the organic nature of its growth over the 60 years it has been in existence. The campus is connected by a series of underground tunnels, which comes in handy during the frigid winter temperatures which are often accompanied by wind and snow. The laboratory has a phlebotomy area that is located in the main hospital building. The accessioning department is located across the street from the main hospital building. There are multiple floors and departments spread across the campus that perform their own collections instead of sending their patients to the phlebotomy area for specimen draws. Each of these areas has their own specimen pick up area with a specimen bin for room temperature specimens as well as a small refrigerator and freezer for proper specimen storage. The hospital does not have a pneumatic tube system or robots to pick up specimens, therefore it has a courier that makes rounds every hour. The courier is not just visiting the different departments’ specimen pick up areas. The last stop on their route is the phlebotomy area, which is the single area collecting  most specimens. The entire route takes approximately 20 minutes without stopping for questions or to resolve issues. The phlebotomy area is a 4 minute brisk walk through the tunnels from the pre-analytical area, while some of the areas are as far as 10 minute walk from the preanalytical department. The problem with this system is that if a specimen is placed in the specimen pick up tub for the courier right after a courier has visited, it will be about an hour until that specimen makes it to the laboratory. If it is a Stat order, it may be beyond turnaround time (collection to reporting) before it even arrives in  accessioning area. For Stat specimens, the nurse or medical assistant placing the specimen in the bin is supposed to make a call to the accessioning department to notify the lab that there is a Stat, however this call is only placed 15% of the time due to the nurses’ busy schedules. The quality metrics provide objective evidence that there is a problem. Twenty percent of Stat tests (such as troponin, Prothrombin time, CKMB and INR) were beyond established turnaround time thresholds. The hospital has set a goal of at least 95% of Stat tests performed within turnaround time.

This situation is obviously unacceptable for patient care, so the laboratory professionals and the providers ordering the testing would like to make improvements to this system. There is no room in the budget for this improvement project and no ability to make capital purchases to purchase a pneumatic tube system or a robot. With this knowledge, an interdisciplinary team of laboratory (phlebotomy, quality, operations, courier and pre-analytical) staff and nurses from the different departments was convened for this improvement project.  They began by brainstorming ways to make the internal specimen transport process more efficient for Stat specimens and thus improve patient safety. They started with visual indicators to more effectively differentiate Stat specimens. Every Stat specimen was to be placed in a red tinted biohazard bag that had STAT written on it in bold letters. Whenever a nurse or phlebotomist collects a Stat specimen, they place a red card in a predetermined location on the wall near the specimen bin. A blue card is placed for routine specimens. With the help of the IT and information security departments, inexpensive (~$25/each) wireless cameras were installed and positioned to view the Stat and Routine Specimen Cards. There were no HIPAA concerns as the cameras were positioned to only view the Stat and/or Routine Specimen cards and the video feed had no sound. An existing LED television screen in the Pre-analytical department was utilized to view the 8 different live feeds simultaneously from each department which were labeled with their corresponding areas on the screen. The couriers were also given an iPad (which the department owned)  that also simultaneously displayed the live feeds from the cameras near the bins using an app so they could view the images while they were on their routes. It is helpful for the couriers to see which areas have specimens in the bins (either routine or Stat) as if the bin is empty, the courier can skip that stop which results in more efficient routes and can contribute to faster turnaround times. The couriers would remove the cards from the view of the cameras upon pickup of the specimens. When work in the preanalytical department was slow and a red card was displayed, even if it was not a typical courier pickup time, they could go directly to that area to pick up the specimen. This was particularly helpful for Stat pickups in the phlebotomy area (the area with the highest specimen volumes for both Stat and routine specimens) as the entire trip was only an 8 minute trip from the accessioning area.

This entire improvement project cost the hospital $200 for cameras, $10 for the laminated red and blue cards, and $350 in information security and IT time for a grand total of $560 (not including the interdisciplinary team’s wages for meeting times). All other equipment and supplies utilized for the project were already owned by the hospital. Within 30 days of implementation of the cameras, the hospital achieved its goal of 95% of Stat tests performed within turnaround time thresholds. This project enabled the hospital to improve its performance on four of the six quality aims published by the Institute of Medicine (IOM) which are highlighted below1.

  • Patient care became more timely as a result of this project. The average turnaround time for Stat specimens decreased by 15 minutes.
  • The specimen transport system became more patient-centered, as it is now focused on the turnaround time needs specified by patients’ physicians instead of a routine route that is convenient for the laboratory staff.
  • The specimen transport routes became more efficient, eliminating wasted trips to empty bins and streamlining routes for Stat specimens.
  • Patient care provided at the hospital became safer as a result of the improved Stat turnaround times due to a reduction in treatment delays caused by extended turnaround times.

Additionally, this project enabled the participants to use four of the five core competencies needed for healthcare professionals as defined by the IOM2 (refer to Figure 1), including working in interdisciplinary teams, applying quality improvement, utilizing informatics and most importantly, providing patient centered care.

Figure 1: Relationship of core competencies for healthcare professionals. Source: Institute of Medicine (US) Committee on the Health Professions Education Summit; Greiner AC, Knebel E, editors. Health Professions Education: A Bridge to Quality. 2

This case study highlights the fact that not all quality improvement projects require substantial financial investment or a sophisticated solution. Oftentimes in the laboratory and in healthcare as a whole, we are limited financially. I have encountered countless examples of simple, effective solutions to quality issues in the laboratory. I am constantly impressed by the creativity and resourcefulness of medical laboratory scientists and other healthcare practitioners. The next time you face a quality issue in your laboratory, I challenge you to think outside the box to improve quality and patient safety for the benefit of your patients.

  1. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press; 2001.
  2. Institute of Medicine (US) Committee on the Health Professions Education Summit; Greiner AC, Knebel E, editors. Health Professions Education: A Bridge to Quality. Washington (DC): National Academies Press (US); 2003.

About The Author

Jennifer Dawson, MHA, LSSBB, CPHQ, DLM(ASCP)SLS, QIHC, QLC, is Sr. Director, Quality for Human Longevity in San Diego, CA. She sits on the CLSI Quality Management Systems Expert Panel, the ASCLS Patient Safety Committee and the AACC Management Sciences & Patient Safety Division Executive Committee. Jennifer has also recently served on the National Malcolm Baldrige Quality Award Board of Examiners and the CLMA Board of Directors. She is a frequent presenter and publishes articles in trade magazines and journals on the topic of quality in a clinical laboratory. Her areas of interest include ISO 15189 and Baldrige Framework deployment, real-time quality metrics, cost of poor quality, electronic management of non-conformities, creating a culture of quality, and quality in the pre-analytical phase. She’s a Lean Six Sigma Black Belt, a Certified Professional in Healthcare Quality, a Diplomate in Laboratory Management certification from ASCP and is a fellow of the American College of Healthcare Executives. She is also Health Services Administration faculty at Regis University.