This document summarizes the learning from pilot projects aimed at improving phlebotomy services using Lean methodology. Key findings include: understanding patient data is important to improve performance; observing processes from the patient perspective reveals opportunities; establishing clear standards helps focus improvement efforts; and fixing phlebotomy in isolation may not impact broader patient pathways. Common themes across sites included managing services with data, training staff in Lean tools, improving communication, and reducing waste.

1. NHS
CANCER
NHS Improvement
Diagnostics
DIAGNOSTICS
HEART
NHS Improvement - Diagnostics
LUNG
First steps in improving phlebotomy:
The challenge to improve quality,
STROKE
productivity and patient experience
May 2011

2. “
When considering improvement projects and
particularly when seeking to use Lean methodology,
it is key that we understand the service from the
patient’s perspective. It is surprising what can be
observed and some simple suggestions for
improvement that can come from these
observations.
Apply the same methodology to as much of the
processes as is possible, don’t blindly accept that the
”
current process is the best way of delivering.

3. 3
First steps in improving phlebotomy: The challenge to
improve quality, productivity and patient experience
Contents
Foreword 4
Executive summary 5
Why phlebotomy? 6
Summary of learning 7
Understanding the needs of patients and users 10
Telling the patient story 11
Our approach: Lean thinking - putting patients first 12
Project approach 14
Pilot sites 16
Case studies 17
• Doncaster Royal Infirmary - Outpatient phlebotomy improvements 17
• Doncaster Royal Infirmary - Increased phlebotomy productivity 22
on inpatient wards
• Whiston Hospital (St Helens & Knowsley) - A&E Department - 25
Reduced turnaround times (TAT), reduced admissions
• Whiston Community Clinics (St Helens & Knowsley) - Scheduling and flow 27
of clinic start time
• West Middlesex University Hospital - Dedicated ward phlebotomist 29
• West Middlesex University Hospital - Phlebotomy column on real-time 31
patient management whiteboard
• West Middlesex University Hospital - Early morning bleed 34
• Warwick Hospital - Earlier start for bleeding patients 36
• Russells Hall Hospital (Dudley) - Faster return of specimens from acute ward 38
Contacts 40
References 41
Useful reading 42
Acknowledgements

4. 4 Foreword
Foreword
Pathology services lie at the heart of healthcare services provided to patients as
they are essential to the delivery of 70% of all clinical interventions affecting
diagnosis, treatment and long term monitoring of care. The vision for NHS
pathology services puts patients first by providing services which are:
• clinically excellent
• responsive to users
• cost effective
• integrated.
Effective phlebotomy services are the first step to providing quality pathology
Dr Ian Barnes
tests. Phlebotomy services can be provided by a range of healthcare National Clinical Director for
professionals in a wide variety of settings. Wherever they are provided, it is Pathology
essential the patients needs are considered to ensure samples are taken as local
to the patient as possible, with ease of access, in a timely manner that allows
early decision making regarding patient, diagnosis, treatment and monitoring.
The pilot sites supported by NHS Improvement have clearly demonstrated that a
greater patient focus and improvements in quality of services can be achieved by
applying small measurable changes that have significant benefits.
I would endorse and commend this document as a first step in improving
phlebotomy services.
Dr Ian Barnes
National Clinical Director for Pathology

5. Executive summary 5
Executive summary
In Lord Carter’s review of pathology Key learning has demonstrated
services, the importance of improving success is achieved through:
access to phlebotomy was
referenced. Working in partnership The power of data
with the Department of Health Understanding current performance
Pathology Programme, NHS is key and enables services to get
Improvement supported four pilot back in control of their performance,
sites to test whether Lean however, getting this information
methodology could meet the can be difficult.
challenge of improving the quality,
productivity, and patient experience “Getting hold of good
for phlebotomy services.
consistent data has been a
Multidisciplinary teams worked challenge”
collaboratively to test and implement
changes that deliver improvements Go and see
for patients, staff and users of the “Unless you understand the
service. problem and what it entails
Staff were trained to apply Lean
and get all the details, you Staff trained in Lean
methodology to their work, the can’t do anything. Go and methodology
intention being to ensure continuous look for yourself to get the Training and empowering staff to use
improvement beyond the period of information.” tools and techniques to focus on
NHS Improvement involvement. seeing and removing the wastes.
Make use of tools and techniques to
Phlebotomists’ calling through
Some of the improvements focus the service around the
patients for bleeding
included: customer.
• 59% reduction in average waiting
“Only when we sat in the
time for patients attending the waiting room as a patient “Process mapping was a great
walk-in phlebotomy clinic did we see that the system tool to make our process
• 32% increase in phlebotomy of calling through patients
productivity on wards, from 8.85 visible and highlight the
to 11.7 patients per hour wasted time, and by wastes. Understanding our
• 19% reduction in the turnaround implementing a simple capacity and demand was
times for viewing a blood result in change we saved time.” important’’.
A&E from time the blood was
taken
Establishing measurable Next steps
• 100% reduction in phlebotomy
standards We now recognise this is a vast area
service related complaints, with
To allow users and providers to of opportunity and further work is
positive comments now being
deliver integrated clinical pathways ongoing which will be shared in the
regularly received
to manage effective patient care. future.
• 76 % reduction in staff absence
• 22% increase in number of
patients bled within 15 minutes
of arrival due to improved staff
scheduling.

6. 6 Why phlebotomy?
Why phlebotomy?
Each year in England approximately
800 million pathology tests are
processed and reported, costing the
NHS an estimated £2.5 billion per
annum, of these 90% involve the
taking of a blood sample. As with
many areas of the NHS demand
continues to increase and the
pressing challenge facing pathology
services is how to deliver more for
less. This challenge was articulated by
Lord Carter in his review of Pathology
Services where he concluded 20% or
£500 million was the scale of the
opportunity. Focussing on:
• Improving access to
phlebotomy
To facilitate the delivery of an
efficient and high quality service
which is responsive to the needs
and wishes of patients, with
samples collected at times and in
places which are convenient for
patients. (Lord Carter Report of the
second phase of the independent
review of NHS Pathology Services
in England).
Lord Carter in his review of pathology NHS Improvement was tasked to
• Establishing performance recognised that: ‘In this country, it is address some of the issues of
standards generally phlebotomists who collect phlebotomy services and in particular:
Clear performance standards samples from patients in hospital and
for the delivery of the service those attending outpatient clinics”. • Improving access to phlebotomy
should be developed, and for With this scale, phlebotomy offered services for patients and clinicians
ensuring the effective use of the greatest opportunity to focus on • Improving productivity to provide a
the pathology service. a patient facing process, bring issues more cost effective service
to the surface, and contribute to • Improving patient experience
• Improving quality and safety: significant improvement. • Investigating the impact efficient
• Quality of service to the public phlebotomy services can have on
• Clinical quality (by reducing the whole patient pathway by:
specimen labelling errors) • Admission avoidance
• System quality. • Reduced length of stay.

7. Summary of learning 7
Summary of learning
What we have learned?
‘Voice of the project leads’
We started out to explore
phlebotomy services to understand if
improving efficiencies, and access can
have an impact on the whole patient
pathway, speeding up decisions to
treat, avoiding admissions and
ultimately speed of discharge and
length of stay. So what has been
learned?
It is challenging
Whilst many of the trials, pilots, and
improvement suggestions seem
simple making them happen is not
easy. Common sense it seems is not
common practice. Change is never
easy and any improvement project
will require dedication, focus and
clear outcomes to maintain
momentum and deliver results, issues
which are compounded when staff
on pilot sites tried to drive
improvement projects as well as
doing the day job.
“ Allocating time and fitting it
around the day job has been
really difficult.” Without national targets and goals ensuring staffing levels are
means that performance data outside appropriate to meet anticipated
The power of data of A&E is rarely collected and demands; Delivering a predictable
Understanding current performance analysed. Simply understanding daily service to patients whilst resources
is key and enables services to get and hourly demand allows staff to be are used efficiently.
back in control of their performance, in better control of the service,
however getting this information can
be difficult.
“ Rota management and staff capacity has improved as a result
“ Getting hold of good of understanding the data. Waiting times were on the increase
consistent data has been a and seeing where additional hours and staff were needed has
challenge.” helped improve things.”

8. 8 Summary of learning
Go and see Establish measurable standards - “On the wards they have
Make them visible
much bigger issues like bed
“Unless you understand the Base lining the phlebotomy service
highlighted the lack of clear management and IT
problem and what it entails
measurable standards that were systems.”
and get all the details, you visible to staff and users. Establish
can’t do anything. Go and clear measurable standards in Common themes
look for yourself to get the conjunction with users to ensure that While there were a number of
the service is focused on patients’ improvement suggestions trialled
information.’’ needs and best outcomes. If there is with varying degrees of success there
some measure of good performance appear to be some common themes
“Encourage staff to view the this seems to add clarity and focus to and learning.
service from the patients what everyone is trying to achieve.
Manage with data
perspective. Asking the staff In Doncaster, a maximum 30 minute Collect and understand data, use it to
to sit and watch helped them wait time standard was set. design the service. Manage the flow
to identify the key wastes.’’ by reducing peaks and troughs and
“Staff focused on the 30 keep the service as efficient as
“ When considering minute standard and this has possible. Share performance data
with staff and users. Establish
improvement projects and been really successful.” dashboards to display metrics and
particularly when seeking to empower staff to fix problems daily.
use Lean methodology it is Phlebotomy in isolation?
The feedback from pilot sites was Staff trained to apply Lean tools
key that we understand the that while there were key areas of Train and empower staff to use tools
service from the patient’s focus that delivered tangible benefits and techniques to focus on seeing
perspective. It is surprising phlebotomy in isolation cannot and removing the wastes. Make use
what can be observed and deliver the significant benefits to of tools and techniques to focus the
discharge and other hospital service around the patient needs.
some simple suggestions for processes. When asked at the start of
improvement that can come the process whether phlebotomy was Communication
from these observations. an issue many replied it was, but Most of the sites piloted ideas to
once improvements were made it
Apply the same methodology improve communication between
became clear that issues with other phlebotomists and ward staff
to as much of the processes diagnostic pathways, bed providing a range of benefits.
as is possible, don’t blindly management, discharge letters and Phoning ahead to manage demand
accept that the current pharmacy required improvement. gave phlebotomists the chance to
process is the best way of know what level of work was waiting
Fixing phlebotomy in isolation does on the wards and respond. Simple
delivering.’’ not have a profound effect on the visual flags to indicate when
whole patient pathway, but the phlebotomists were on the ward,
benefits are still significant to the indicating when patients had been
patient, and can deliver efficiencies. bled so doctors did not have to waste
time checking.

9. Summary of learning 9
Common wastes
Significant efficiencies were found
across the sites by simply focusing on
common wastes identified through
process mapping and observing the
process. Reduce walking by having
phlebotomy trolleys stocked on the
ward, to an agreed standard.
Dedicated phlebotomists
Having phlebotomists dedicated to
wards and outpatients across a
number of sites increased
productivity as measured by bleeds
per hour. It appears that this is the
result of better working between
ward and phlebotomy staff,
increased communication, and
phlebotomists starting to build
relationships with patients on the
ward. Recognising the need for
blood samples to be taken as soon as
the decision is made for the test will
require non phlebotomy staff to
provide this service out of core hours.
Delivering samples to the
laboratory
Understand when ward rounds take
place. Ensure that blood results are
available for rounds by bleeding
patients earlier in the morning.
Employ Porters or volunteers to
collect and deliver samples little and
often to the laboratory. Utilise air
tube systems where available.

10. 10 Understanding the needs of patients and users
Understanding the needs of patients and users
The importance of patient
feedback
A number of websites exist where
patients are encouraged to provide
feedback on their experience. One
example is
www.patientopinion.org.uk
The first challenge – Have you
looked at the feedback about your
organisation on this website?
The second challenge - Who is
responsible for providing feedback to
comments made about your
organisation?
“
The doctor saw her on Friday morning and
said she could go home but the nurse pointed
out that there were some blood test results
that were still to arrive and he then agreed to
“
Waiting for results
seemed to be a
”
keep her in hospital until Monday.
delaying factor - I felt
Patient relative
that more rapid
results could have
“
saved some of my bed
”
occupation time.
My partner was waiting in A&E (after triage)
Patient
for two hours while blood tests could have
been run - eventually when blood was
taken she had to wait another two hours
”
for results.
Patient relative

11. Telling the patient story 11
Telling the patient story
Before embarking on wholesale
changes to phlebotomy services it is Time from arrival in department to result viewed
important to understand and define
value from the patients’ perspective.
Long delays from request to bleed Long delays from result
This is central to understanding what (ownership, capacity, productivity) available to result viewed
is important to patients and clinicians 4 Hour A&E Target or acted upon
and provided areas to focus the
improvement. This took the form of
data analysis, stakeholder and staff
50 mins 28 mins 47 mins 1 hour 20 mins
feedback, and patient experience.
The end-to-end pathway provided
evidence of the improvements
already made in laboratory processes,
and focussed on the potential for
improvement in other parts of the
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
pathway
Often we only look at the laboratory, Arrival to collection Collection to booked
but it is in the whole pathway where
Booked to reported Reported to viewed
the big wins appear to be.
The Emergency Care Pathway:
Whiston Hospital
There were perceived delays in the
laboratory that were causing patients PATIENT STORY
to breach the A&E four hour target.
As a result of working with the The inpatient pathway
Emergency department team we The following is a patient story of how poor processes can have a
have been able to identify the dramatic effect on the patient:
complete blood pathway and have
engaged with key staff from the • Specimen taken 7.30 a.m. (for Gentamicin levels) - phlebotomist noted
Emergency department. ‘patient very collapsed and not enough blood to do U&E, Full Blood
Count and Gentamicin’
• Sample arrived in the laboratory 8.30 a.m.
• Local lab analyser has been defective for the last 14 months (policy is all
microbiology samples are analysed at hospital 10 miles away)
• Lab staff spent two hours trying to contact the Senior House Officer (SHO)
to ascertain which test was more important the U&E or the Gentamicin?
• Sample put on first transport to external lab at 10.30 a.m.
• Result back on ICE (I.T. System) at 11.45 p.m.
• SHO contacted at 1.46 a.m. regarding result
• Phlebotomist didn’t realise the significance of not being able to get
blood out for this patient at 7:30 a.m. (i.e. collapsed from septic shock?)
• Nurses left in a quandary as to whether to give the three more doses of
Gentamicin due at 8.00 a.m. 4.00 p.m. and midnight.

12. 12 Our approach: Lean thinking - putting patients first
Our approach: Lean thinking -
putting patients first
“
Too often, patients are expected to fit around
”
services, rather than services around patients.
Liberating the NHS –
Department of Health White Paper (December 2010)
At the heart of Lean thinking are
customers, our patients, and seeking
to understand what parts of our
processes they believe are valuable. In
our experience with or as patients we
“
Lean thinking is a way of streamlining the
patient journey and making it safer, by helping
staff to eliminate all kinds of waste and to treat
”
may all agree that of value is safe,
timely, high quality care. Very few of
more patients with existing resources.
us would consider waiting, queuing,
endless paperwork, or mistakes to be Jones, www.leanuk.org
a valuable part of any service we
would be prepared to pay for.
The Benefits of Lean
The key to lean improvement is:
“
Any process or value stream Improved customer
satisfaction
Go see, ask why, and Lead Time / Cycle Time • Reduced waiting
understand the root • Better delivery
Before • More capacity
cause of the problem • Better quality
”
• Improved productivity
you are solving. • Improved safety
After
David Fillingham, Lean Healthcare
Lean attacks waste here
Work ... value added time Wait/waste ... non value added time
Reduced waste, improved customer experience

13. Our approach: Lean thinking - putting patients first 13
Continuous improvement in Lean
methodology focuses on five key steps
1. Specify value - The elimination of
waste is the main characteristic of Specify VALUE from
Lean. Waste is everything that the customer viewpoint
doesn’t add value to the patient or
process. There are three types of
work:
Pursue
PERFECTION in Identify the
• Value add – When you are adding VALUE STREAM
quality and
value to the patient/process (e.g. quantity by and remove
prescribing medication, providing continuous Introduce Standard Working waste
physiotherapy, reporting an image) improvement Remove Waste
Set Up Visual Management
• Necessary waste – When you are Eliminate Batching
not adding value but it is a Identify Root Cause
necessary step. (e.g. incubation in a
microbiology laboratory)
• Unnecessary waste – Where you
are not adding value and these
steps could be removed (e.g.
walking to get or find items, initiate PULL in line Make value
with customer demand FLOW
waiting for staff, machines and
medication).
The wastes can be remembered by
the name TIM A WOODS (Lean
office at Cooper Standard, 2. Identify the value stream steps 5. Continually improve and strive
Plymouth UK) - A current state value stream map is for perfection - Continuous
a visual representation of all the improvement is the final lean
actions currently required to deliver a principle, which is to strive for
T TRANSPORT product or a service. perfection through continuous
I INVENTORY improvement. It is important to
3. Make value flow - Flow is the develop staff and give them the
M MOTION continual movement of value adding capability, autonomy and
activities from the beginning to the empowerment to solve the problems
end of the value stream. Processes as they encounter them on a daily
A AUTOMATING which add value to the patient basis.
(an inefficient process)
should not be held up by any non
W WAITING value adding steps or waste in the “More often than not the
system.
O OVER PROCESSING process is to blame not the
4. Pull value through the process people. To improve the
O OVER PRODUCTION
from actual demand - Flow and pull process do so by striving for
D DEFECTS work to keep the entire value stream ‘clinical excellence in
moving. “Flow where you can, pull
partnership with process
S SKILLS UTILISATION where you must” Jeffery K. Liker, The
Toyota Way, 2004 excellence’.”
Reference: ‘Bringing Lean to Life’, Continuous improvement in
NHS Improvement
Cytology, NHS Improvement

14. 14 Project approach
Project approach
The experience from previous
learning has demonstrated that the Factors for achieving sustainable improvements
factors in the graphic on the right are
vital to achieving sustainable
improvement.
Understand the current process
In healthcare, we are used to taking
clinical measures such as
temperature, pulse, blood pressure,
respiration rates, urine outputs etc in
order to understand the current
status and demonstrate if conditions
are getting better or worse.
Project timeline
Identify Evaluate
Data Pilot
the and
analysis solutions
wastes sustain
To improve your current process, data
is required to understand the root
cause of the problem you are trying
to address, a set of measures need
to be agreed.
It isn’t always easy to collect data for Map the process
Measures might include: this baseline. If you can’t get the A critical starting point in any
• Quality – End to end information from the electronic problem solving or improvement
turnaround times systems, you will need to collect the work is to map the process in its
• Cost – Improve productivity information manually. current state. One of the tools used
• Morale – reduce staff time doing to capture the current state or ‘as is’
wasteful activities Data and measures are also performance is the value stream map
• Patient experience – reduction in important to demonstrate and prove (VSM).
waiting times. that change has occurred, and what
difference this makes for all those Current State VSM
involved in the process including A current state value stream map is a
patients and staff. Whether the visual representation of all the actions
change was a success or a failure, currently required to deliver a product
you still need to demonstrate it! or a service. The output however is
more than just the current state, you

15. Project approach 15
also look to map where the value in
the process happens, and where PDSA cycle for learning and improvement
waste in the process is. This then
guides group discussions and
problem solving to produce tangible
solutions and ideas to reduce the
waste and increase the value in the ACT PLAN
What changes Objective
process. Remember as defined earlier are to be made? Questions and
Next cycle predictions (why)
in this booklet value can only be Plan to carry out the
defined by the end customer. In cycle (who, what,
where and when)
healthcare the customer is usually the
patient. Value is any activity that STUDY DO
directly contributes to satisfying Complete the Carry out the plan
analysis of the data Document problems
needs of the patient. Any activity that Compare data to and unexpected
predictions observations
doesn’t add value is defined as Summarise what Begin analysis
waste. was learned of the data
Future State VSM
Once you understand the current
picture of what really happens
throughout the value stream, you can
begin to agree what needs to happen
and then analyse the gap between
the current and future states. From Once suggestions for improvement the only sustainable way to strive for
your current state map you will be have been tested on a smaller scale perfection.
able to identify where the significant and demonstrated they work, only
problems occur. This might be the then can we we roll out those Areas to focus on
most prevalent waits and delays, the changes across the whole service. Having defined patients’ value, the
largest amount of work in progress This will require planning, mapping, waste identification and
between process steps or where consideration for potential obstacles, staff discussion began to focus on
there is considerable duplication. and a plan to manage those changes. key areas and potential for
Once the future state Value Stream However, changes are made in the improvement:
Map is completed, it is then essential knowledge that they have been
to review measures, analyse the gap piloted, have demonstrated their • Understand the end to end
between current and future state success and how they improve the pathway – don’t assume the fault
and then agree an action plan to trial process. lies with the laboratory
the changes. • Capacity and demand –
Continuous improvement understand daily/hourly demand
Take action and pilot solutions Continuous improvement is the final and capacity
Take action, pilot suggestions for Lean principle, which is to strive for • Use visual management to
improvement, measure the effect and perfection by embracing the Lean demonstrate performance
continue to improve until you have a philosophy and tools. The staff are a • Engagement with clinical teams
workable solution to reduce waste. fundamental part of Lean. It is • Productivity – How to improve the
Even small scale pilots can provide important to develop staff and give number of patients bled per hour
enough data and feedback to them the capability, autonomy and • Use the evidence to design the
establish if the solution delivers empowerment to solve the problems service.
benefits and increases value, before as they encounter them on a daily
rolling out large service wide changes basis. Teaching and expecting
that are untested. rigorous problem solving by all staff is

16. 16 The pilot sites
The pilot sites
NHS Improvement worked with West Middlesex University
the following pilot sites: Hospital NHS Trust
The West Middlesex University
Doncaster and Bassetlaw Hospital is a busy urban acute
Hospitals NHS Foundation Trust hospital located in Isleworth, West
(Doncaster Royal Infirmary) London providing services primarily to
Doncaster Royal Infirmary is one of residents of the London Boroughs of
the key hospitals in the Doncaster Hounslow and Richmond upon
and Bassetlaw Hospitals NHS Thames. Employing some 2,250
Foundation Trust. The hospital people (including our partners in
provides a full range of services Ecovert FM), the hospital has over
appropriate to a large district general 400 beds. The Trust has an annual
hospital in 800 beds. Each year the budget in excess of £130 million and
hospital treats around 150,000 provides services to a population of
patients along with 95,500 A&E around 400,000.
patients (combined figures for
Doncaster Royal Infirmary and The Dudley Group of Hospitals
Montagu Hospital). NHS Foundation Trust (Russell’s
Hall Hospital)
St Helens and Knowsley Teaching Russell’s Hall Hospital is the largest of
Hospitals NHS Trust (Whiston three hospitals in The Dudley Group
Hospital) of Hospitals providing the full range
Whiston Hospital is one of two of surgical and medical specialties for
Merseyside hospitals (along with St its inpatient services, together with
Helens Hospital) managed and run by some outpatient and therapy services
St Helens & Knowsley Teaching with over 750 beds.
Hospitals NHS Trust. The new hospital
offers the full range of acute South Warwickshire NHS
healthcare services along with Foundation Trust (Warwick
specialist burns care through the Hospital)
Mersey Regional Burns and Plastic While working with our pilot sites,
Surgery Unit. It has 15 operating NHS Improvement had an
theatres, diagnostic facilities, and opportunity to link with South
over 800 beds. Warwickshire NHS Foundation Trust
who are taking part in a flow cost
and quality programme with the
Health Foundation.

17. 17
ONE.
CASE STUDY
Doncaster Royal Infirmary
Outpatient phlebotomy improvements
Summary How the changes were
59% reduction in average waiting implemented
time for patients attending the walk-
in phlebotomy clinic at Doncaster • Numerous formal and informal
Royal Infirmary (DRI) meetings and discussions with the
phlebotomy team to agree
Understanding the problem changes.
Patients attending the phlebotomy • The walk-in clinic relocated to the
walk-in service at DRI often had to main out-patient area.
wait over an hour to have their • A patient queue management
blood taken. Regularly it was system was installed. This system
standing room only in the waiting enables each phlebotomist to call
area, staff morale was low and staff the next patient through to their
absence was high. The long waiting cubicle as soon as they are ready,
times for phlebotomy led to knock- using a small keypad. The patients
on problems in outpatient clinics, see a number display and hear an
leading to complaints from clinicians audible announcement in the
and patients. A high number of A receptionist recorded the waiting waiting area. The keypad informs
primary care patients also attended time for phlebotomy on the hour, the phlebotomist how long the
the walk-in service and were equally every hour over many months. patient has waited to be called,
dissatisfied with waiting times. and how many people are in the
Staff issued a questionnaire to all queue.
The phlebotomy area was co-located patients attending the walk-in clinic • A dashboard was developed,
with the pathology laboratory so all throughout the week of 23-27 utilising the output data from the
outpatients had to travel round the November 2009, to provide patient queue management
hospital site to have their blood feedback on why they had chosen to system. The team print the
taken. Patients reported to a attend DRI for phlebotomy and to dashboard to create a very visible
receptionist as they arrived, who gain information about how long display of daily, weekly and
checked their identification and they had to wait. monthly performance.
placed their request form in a box in • Demand information was
order of arrival. As each Phlebotomists sat in the patient requested from every inpatient
phlebotomist became free, they took waiting area and observed the ward each morning before the
the next request form from the box, process from the patients’ point of phlebotomy round started to assist
walked out into the waiting area, view. Phlebotomists timed each overall rota management.
called the patient by name and stage of the process and then • The staff rota was co-coordinated
waited for the patient to respond agreed which steps were value across inpatient services and the
and return to the blood taking area creating and which were ‘waste’. walk-in clinic to match capacity to
with them. demand as closely as possible,
with a number of changes being
made over time.

18. 18
Measurable outcomes
and impact Reduction in average waiting time
• 59% improvement in average 25
waiting time. Pre improvement Post improvement
• Average waiting time improved
Average waiting time (inpatients)
from 18.6 to 7.6 minutes. 20
• 53% improvement in maximum Average waiting time
waiting time
15
• Maximum waiting time reduced
from 87 to 41 minutes (averages
per month) 10
• Reductions in average and
maximum waiting times achieved
despite increasing demand, and 5
with no increase in staff numbers.
• 12,699 hours of waiting time 0
saved since improvement work Aug Sep Oct Nov Dec Jan Feb Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
09 09 09 09 09 10 10 10 10 10 10 10 10 10 10 10 11 11
(approx. 1,154 less waiting hours Month
per month).
• Feedback has been hugely
positive, transforming 10 written
complaints in 2009/10 to 21
written compliments in 2010/11 Reduction in maximum waiting time
along with hundreds of verbal 140
compliments. Pre improvement Post improvement
Maximum waiting time (inpatients)
120
The following quotations are taken
from some of the written 100
compliments received: Maximum waiting time
80
“I have been attending 60
phlebotomy for 12 years as a
patient of Dr M. Since your 40
reorganisation in the last few
20
months, the reduction in
waiting time is both 0
Aug Sep Oct Nov Dec Jan Feb Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
significant and welcome. 09 09 09 09 09 10 10 10 10 10 10 10 10 10 10 10 11 11
Month
Well done in improving so
much the patient
experience"
“ This is so much better than before, in and out,
clean area and friendly staff”

19. 19
• Feedback from clinicians has been
Reduction in waiting time while activity increases equally positive, with many
140 8,000
consultants contacting
Pre improvement Post improvement phlebotomy staff to inform them
120 7,000 how pleased they are that their
patients are being seen quickly.
Waiting time (inpatients)
6,000
100 • No issue with seating in the
5,000 waiting area as the queue does
80 not build up.
4,000
• Most outpatients do not have to
60
3,000
travel round the hospital corridors
to have their blood taken, as
40
2,000 phlebotomy is now co-located in
20
the main outpatient area. In
1,000
addition, the free park and ride
0 0 bus stops just outside the
Aug Sep Oct Nov Dec Jan Feb Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
09 09 09 09 09 10 10 10 10 10 10 10 10 10 10 10 11 11 phlebotomy and outpatient
Month waiting area.
Maximum waiting time Average waiting time Attendees • Staff morale has improved
significantly. The phlebotomy
team meets regularly in work
hours. Communication folders
Staff absence - Phlebotomy (DRI) and notice boards have been
introduced and most staff
10 participate in social functions
Pre improvement Post improvement
9 outside work:
8
• Since the improvement work
Phlebotomy commenced, staff absence has
Percentage absence
7
reduced from 6.6% to 1.6%
6 over the last twelve months.
5
• 926 more staff hours at work
that were previously absent in a
4
year.
3
2
1
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
09 09 09 09 09 09 09 09 Dec 10 10 10 10 10 10 10 10 10 10 10 10 11 11 11
Month

20. 20
Ideas tested which were Daily dashboard example
successful
• Installing patient queue
management system:
• Removing waste (phlebotomist no
longer going into waiting area to
call patient).
• Phlebotomist able to see waiting
time of current patient and
number of patients in queue on
keypad.
• Dashboard displays created using
data from system – to make
performance very visible. Daily,
weekly and monthly dashboards
are used (see examples on the
right).
• Data from system used to match
staff rotas (capacity) to demand as
closely as possible.
• Reducing phlebotomy hours on
inpatient wards and moving them
to walk-in clinic.
• Relocating to main outpatient
area.
How this improvement benefits
patients
• Significant reduction in waiting
time for patients.
• On average every patient waits
only 7.6 minutes, rather than
18.6.
• Visual and audible display in
waiting area, so improvement for
patients with hearing difficulties.
• Outpatient clinics not held up by
patients queuing to have blood
taken.

21. 21
How will this be sustained,
Monthly dashboard example potential for the future and
additional learning
• Ongoing use of data by
management team and
phlebotomists.
• Visible displays of performance to
staff and patients.
• Roll-out of patient queue
management system, staff
processes and rotas to Bassetlaw
hospital walk-in clinic (positive
patient feedback and evidence of
waiting time improvements used
to achieve business case approval).
• Fine-tuning of staff rotas in line
with demand.
• Data used to support recruitment
as activity increases (evidence for
funding application).
Contact
Sarah Bayliss
Email: sarah.bayliss@dbh.nhs.uk

22. 22
TWO.
CASE STUDY
Doncaster Royal Infirmary
Increased phlebotomy productivity
on inpatient wards
Summary
32% increase in phlebotomy
productivity on wards, from 8.85 to
11.7 patients per hour.
Understanding the problem
• Phlebotomists were frequently
reaching the end of their shift,
running out of time, and leaving
some inpatient wards without a
phlebotomy service. Different
phlebotomists went to each ward
each day, working in pairs, and
there was little or no teamwork
between phlebotomists and ward
staff.
• The phlebotomists were unable to
bleed some patients. A team of phlebotomists and ward • Separate ward and walk-in clinic
• The ward phlebotomists would staff undertook a process mapping phlebotomy teams were
collect together to get specimens exercise. Phlebotomists timed each established.
ready for transport to the stage of the process and the team • Only one phlebotomist goes to
laboratory, have a break, and then agreed which steps were value each ward instead of working in
would phone the manager to creating and which were ‘waste’. pairs, so they are on the ward for
inform her how many patients had Changes were agreed and longer; therefore, there is a greater
not yet been bled. implemented to reduce ‘waste’ and opportunity for the doctor to place
• Staff morale was low and absence thereby increase value as a additional requests.
levels were high. percentage of the total service time. • ‘Phlebotomist on the ward’
• Feedback from wards was poor. magnets are displayed on the
How the changes were ward ‘status at a glance’ boards to
Ward 26 (a respiratory medical ward) implemented indicate their presence.
agreed to work with the phlebotomy • Suggestions from staff from
team to improve the service. process mapping session and other
meetings.
Phlebotomy representatives observed • Demand information was
what was happening on ward 26, requested from every inpatient
then met with a team of staff from ward each morning before the
ward 26, listened to their views of phlebotomy round started.
the phlebotomy service and • The staff rota was coordinated
ascertained what changes they across inpatient services and the
would like. The phlebotomists then walk-in clinic to match capacity to
shared this information with their demand as closely as possible,
colleagues. with a number of changes being
made over time.
• Every ward was asked to indicate
their ideal time for the
phlebotomy round.

23. 23
• Same phlebotomist on each ward
each day, so soon built rapport Staff absence - Phlebotomy (DRI)
with ward team. Also got to 10
know ‘their’ patients, so fewer Pre improvement Post improvement
9
unable to bleed events.
• Ward phlebotomy trolleys were 8
Phlebotomy
Percentage absence
established, rather than 7
phlebotomist having to transfer a
6
trolley between wards (reduce
time waiting for lifts, and improve 5
infection control) and a standard 4
layout agreed for each trolley.
3
• Pilot on ward 26 to test out
changes. 2
• Discussion at matron’s meetings to 1
agree roll-out across all wards.
0
• Proposed trolley changes Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
09 09 09 09 09 09 09 09 Dec 10 10 10 10 10 10 10 10 10 10 10 10 11 11 11
coordinated as part of electronic
Month
requesting and reporting system.
Measurable outcomes
and impact
• 32% improvement in Ideas tested which were • Use of ward-based trolley for
productivity on inpatient wards. successful phlebotomy, rather than taking a
• 33% reduction in phlebotomy • Establishing a ward-based trolley from phlebotomy round
staff hours on inpatient wards, phlebotomy team. every ward.
yet wards no longer left without a • Named phlebotomist per ward. • Standard layout for every trolley
service. • Only having one phlebotomist to agreed and implemented.
• Positive feedback from ward staff service each ward, so they are on
and phlebotomists. the ward for a longer period. How this improvement
• Reduction in number of ‘unable to • Displaying ‘phlebotomist on ward’ benefits patients
bleeds’. magnets. • Happier staff.
• Staff morale has improved • Delaying coffee breaks until ward • Phlebotomist gets to know the
significantly and phlebotomist work is completed. patients on their wards, which:
absence has reduced from 6.6% • Reducing phlebotomy hours on • increases their success rate at
to 1.6%. The phlebotomy team inpatient wards and moving them obtaining high quality blood
meets regularly in work hours. to walk-in clinics (matching samples.
Communication folders and notice capacity to demand). • means they can spot when a
boards have been introduced and • Changing the order in which request form is missing.
most staff also participate in social phlebotomists attend each ward to • builds rapport with the patient
functions outside work. align the service with ward and helps to put them at ease.
• 926 more staff hours at work that rounds. • Enables blood to be taken as soon
were previously absent in a year. • Varying how specimens are as possible after the clinician
transported to the laboratory to requests it, and transported to the
ensure they are processed as soon laboratory for analysis, thereby
as possible. supporting timely treatment or
discharge of patients.

24. 24
How will this be sustained,
potential for the future and
additional learning
• Ideas piloted on ward 26 have
been rolled out to other wards
following discussion at matrons’
meetings.
• Use of ward-based phlebotomy
trolley to be rolled out as part of
the electronic requesting and
reporting system implementation
(a ‘clinical cart’ is being developed
that will combine provision of IT
hardware and software with the
facility to transport phlebotomy
and other clinical consumables).
• Ongoing use of data by
management team and
phlebotomists.
Contact
Sarah Bayliss
Email: sarah.bayliss@dbh.nhs.uk

25. 25
THREE.
CASE STUDY
Whiston Hospital (St Helens & Knowsley) - A&E Department
Reduced turnaround times (TAT) and
reduced admissions
Background
Whiston Hospital is a new PFI which Whiston A&E blood pathway
opened in March 2010, with 900
3.50
beds, approximately 250 A&E 19% reduction
overall
patients attending per day, 3.21
3.25
pathology had approximately 100 June October
patient bloods per day. The location 2..53
Turnaround Times
of this unit was approximately 100 2.44
2.24
meters away from the existing
pathology service. National target 1.55
POD reliability improved Raised awareness in AED
four hour wait – impact on moving Porter collects sample Coordinator roles
when POD down stablished
patients / admissions high – charges 1.26
Phlebotomist
1.20
to PCT, how could this be challenged trialled in AED
0.57
(see EAU on the following page). 0.50 0.52
0.47 0.47
0.40
0.28
0.28
Summary 0.25
0
As a result of working with the Arrival in AED Collected to boked Booked in lab to Results available Total
Emergency department team we to sample collected in lab system results available to results viewed
have been able to identify the end-
to-end blood pathway and have
engaged with key staff from the
Emergency department. A measure Understanding the problem • Patient blood samples are
of the end-to-end blood pathway To understand and measure the booked in to the pathology
was undertaken, and a process performance of the blood pathway computer - Received
mapping day held to map the within our Emergency services • The pathology process is
patient’s journey. This process department. To investigate the completed (i.e. Emergency
produced an action plan and impact the blood pathway has on department staff are able to
meetings were then held every two hospital admissions. view results) - Authorised
weeks to monitor the introduction of • Results are viewed in the
the changes. This engagement with our Emergency department -
emergency department identified a Viewed.
The process showed an overall possible link between the blood • Hospital admissions (expressed as
reduction in the blood pathway of pathway and admissions to the a percentage).
19%. Trust. We were confident that the
existing blood pathway could be Data was extracted electronically
improved and wanted to use the from both the emergency
hospital admissions data as an department system and the
indicator / measure of this pathology computer. Some manual
improvement. data extraction was also carried
particularly for results viewed. Time
Data collection for this area falls collected was only provided on
under the following headings: approximately 40% of requests.
• Emergency blood pathway Completed data sets were processed
• Patient arrival time in the and the outcomes discussed to
emergency department - improve the level of understanding
Arrived at the appropriate workstream
• Patient has blood collected - meetings.
Transport

26. 26
Outcomes
All relevant departments were Reasons for admission
engaged in the process mapping
100
event. Actions were captured in a
90
plan; this was then delivered over 91
several weeks with varying success. 80
70
Number admitted
The following changes were made:
60
• Take blood samples earlier in the
patients journey. 50
• Transport changes 40
• Trust air tube system – Improve
30
• Improve air tube failure
reporting process 20
21
19
• Improve access to porters 10 14
when/if air tube fails. 8
4
2
0
• Action pathology blood results Awaiting Extended Waiting for Waiting for Waiting for Waiting for Other
Bed Clinical Blood Transport Specialist Imaging
earlier by viewing using patient Pathway Results Opinion
(eg Troponin) (eg Orthopaedics)
enquiry or scrolling screens.
Reasons for Admission
• Improve team work between Trust
phlebotomy team and emergency
assistants, this resulted in
improved coverage of previously
un-staffed sessions. Emergency Admissions Challenges
• Re-launch clinical nursing lead for Unit (EAU) • Consistent engagement over time.
every shift to provide support and This 16 bed unit accepts patients for • Data quality and understanding of
standard working. a whole variety of reasons / the impact.
• Frequent meetings to discuss and conditions. We decided to look in • Extraction of data, time
sustain improvements / introduce detail at four days over a period of consuming and therefore this had
new changes. two weeks. To gather information to be limited.
we used the EAU ward admissions • Introduction of changes /timescale.
Following on from the action plan it register and the trust Electronic • Multi team working, efforts being
was clear that we needed to identify Document Management System made to co-ordinate the different
those patients that had been (EDMS) for all patients admitted over teams.
admitted to hospital due to a delay the period. See results above. • Changes to targets.
in the blood pathway. After • PCT structure /changes.
discussions with the medical The outcome of this work was
admissions unit ward manger we felt shared with the Emergency Contact
it was best to concentrate on a unit department mangers that used this Chris Westcott
called the emergency admissions and other data to introduce planned Email: chris.westcott@sthk.nhs.uk
unit. pathways for specific conditions. This
work is ongoing and therefore the
outcome can not be fully assessed at
this stage. It is felt however that it
will have an impact on the hospital
admission rate.

27. 27
FOUR.
CASE STUDY
Whiston Community Clinics (St Helens & Knowsley)
Scheduling and flow of start time
Along with other national sites we • The data showed the distance We undertook reviews of several
set out to answer the following patients travelled was not phlebotomy areas, one of these
questions: excessive, so choice was areas had recently been handed over
acceptable – No action taken. to our team and we had changed
• Are patients waiting excessive days • The demand on occasions did the service significantly but some
before having blood taken? exceed capacity but this was felt issues remained. This service was
• Are patients waiting for long to be limited, this area needs to be based in a new PFI PCT build called
periods when they arrive at a reviewed on a regular basis as the Newton Community Hospital. The
phlebotomy session? percentage increase in workload phlebotomy service was an on
• Are patients travelling excessively changes. demand service. All patients were
to have blood taken? handed a number on arrival by the
• How is the capacity in relation to This years increase for primary care PCT receptionist, and once our limit
the demand? will see a further 28,000 (M11 had been reached for that session all
forecast) patients being bled other patients were then turned
Understanding the problem compared to the previous 12 months away.
Our initial plan was to concentrate of April 09 – March 10. This equates
on primary care based staff and then to another 1.65 WTE phlebotomy With demand and service provision
incorporate any transferable hours required to deliver this offset, the majority of patients
improvements/changes to our additional capacity - Action taken, waited at least half an hour or more
secondary care based team. As we have increased our service by to be bled:
there was no data available with three additional community sites all
regards to accessing phlebotomy we at the request of the PCT’s, lessons • 50% of patients waited up to
collected data to form a baseline and learnt have been used at these new half an hour to be bled.
enable us to understand the process. sites • 80% of patients were seen in 50
All the data needed to be collected minutes from arrival.
manually. On analysing this data it
was felt that there were long waiting
times for patients to be able to gain
access to phlebotomy clinics and Percentage time to be seen from arrival
then each patient would have
encountered long waits in various 100
settings for their blood to be taken. 90
80
• The data showed that the
community clinic we had chosen 70
showed delays from the request
Percentage
60
being made to the patient arriving
50
to have blood taken but that these
were predominately due to patient 40
choice – No action taken. 30
• The data showed patients who 20
had arrived at a community
10
phlebotomy session were waiting
an excessive amount of time 0
0 to 5 11 to 15 21 to 25 31 to 35 41 to 45 51 to 55 61 to 65 71 to 75
before they had their blood taken mins 6 to 10
mins
mins 16 to 20 mins 26 to 30 mins 36 to 40 mins 46 to 50 mins 56 to 60 mins 66 to 70 mins
mins mins mins mins mins mins
– Main focus for action. Time from arrival

28. 28
Our team decided to drill down our
data and improve the phlebotomy Percentage bled
service at our chosen clinic; we
looked at all the factors below: 80
70
71.9%
• Capacity and demand. January 2010 October 2010
60
• Service delivery - start time.
• Patient flow. 50
Percentage
50.3%
• Staff moral / patient experience. 40
40.7%
30
All of the baseline data required
20
could be easily accessed with the
18.8%
exception of staff moral / patient 10
experience. This was collected by 0
improving staff feedback with senior % in 15 minutes % in 30 minutes
members of staff and monitoring
patient complaints from this clinic.
By starting the service 30 minutes
earlier the phlebotomist was able to Results The PCT staff within the clinic are
reduce the number of patients January 10 happier as fewer patients are
waiting more than 30 minutes • 50% patients bled within 30 complaining, our phlebotomy staff
significantly. We also provide minutes are happier and are returning to the
additional phlebotomy resource on a October 10 main St Helens Hospital base earlier,
Tuesday. We are reviewing the • 72% patients bled within 30 this helps productivity at this site and
requirement for an afternoon minutes. also staff morale as they are
session; however this will depend on supporting their colleagues at St
future workload and demand. January 10 Helens Hospital over lunch times.
• 19% patients bled within 15
From November 2009 – October minutes. Blood samples are returning to the
2010 we received eight complaints, October 10 laboratory earlier therefore
most of these were in relation to • 41% patients bled within 15 turnaround times (TAT) and
patient flow and excessive waiting minutes. reporting to the GP will be
times. A few of these were centered improved, with the number reported
on patients being asked to return to Overall average time to be bled has on the same day being higher than
the clinic another day due to the fallen from 33 minutes in January previous.
capacity being exceeded. The 2010 to 23 minutes in October
number of patients bled per three 2010. Contact
hour session on average is 45. The Chris Westcott
data showed that within the first 250 patients are bled per week, on Email: chris.westcott@sthk.nhs.uk
hour over 25 patients were average 10 minutes per patient time
attending the clinic which made it saved, this equates to more than
difficult for a single phlebotomist to 2,100 hours patient waiting (or 90
match the demand. days) saved per year.