PROJECT NAME: SUSTAINING REDUCED WAIT
TIMES FOR OUTPATIENT BLOOD DRAWS
Institution: The University of Texas M D Anderson Cancer Center
Primary Author: Ron Phipps
Secondary Author: Han Le
Project Category: Sustained CS&E Projects
Choose most appropriate category: 1) Patient Safety, 2) Patient Centered Care, 3) Timeliness,
4) Efficiency, 5) Effectiveness, 6) CS & E Projects Implemented at a New Site,
7) General Quality Improvements or 8)Sustained CS & E Projects
Overview
The Clark and Mays Diagnostic Centers are the top two highest volume outpatient
centers that provide lab services for MD Anderson Cancer Center. These centers
are operated by phlebotomists, patient Service Coordinators and one Medical
Technologist. The Clark Clinic sees 500 to 900 patients per day, and the Mays
Clinic sees 300 to 600 patients per day. For most patients, their blood draw
appointment is their first appointment of the day. Due to patient complaints about
long wait time and congested waiting rooms, we started a project in 2010 to
decrease the wait times in our out patient diagnostic center located in the Mays
and Clark Clinics. Our goal was to improve the turn around time from patient
arrival to specimen collection so that 95% of our patients were seen within 20
minutes of arriving at the outpatient centers.
This project is aligned with the institutional value of Caring, and the Institutional
Strategic Goal for Patient Care (including Strategy 1.2, "We will increase the
quality, safety and value of our clinical care" and Strategy 1.5, "We will enhance
productivity, access and efficiency by strengthening our infrastructure and support
systems." This project is also directly aligned with the “Every Minute Counts”
initiative for Clinical Operations and the impact it has on Press-Gayney patient
satisfaction scores.
Aim Statement (max points 150):
The process improvement project started in 2010 improved the turnaround times in
Mays and Clark clinics dramatically, but did not meet our goal. We continue to
work with the Clark and Mays Clinics to improve the time patients wait to have a
blood specimen collected.
Mays Clinic:
Baseline from Feb 2010:
 Average time of 26 minutes
 44% of patients were collected within 20 minutes
 18% were seen within 10 minutes
Phase I improvement July 2010
 Average time of 18 minutes (a 30% improvement)
 65% of patients were collected within 20 minutes ( a 48% improvement)
 35% were seen within 10 minutes (a 94% improvement)
Clark Clinic:
Baseline from Feb 2010:
 Average time of 15 minutes
 74% of patients were collected within 20 minutes
 40% were seen within 10 minutes
Phase I improvement July 2010
 Average time of 14 minutes (7% improvement)
 82% of patients were collected within 20 minutes ( 11% improvement)
 47% were seen within 10 minutes (18% improvement)
Measures of Success:
We monitor and trend the turnaround time with daily graphs that are available for
review by the supervisor and phlebotomists. The graph is posted on a bulletin
board for the staff to view. The staff was also taught how to interpret the graph.
The measure is based on raw data from the Laboratory Information System, using
the time points from the CARE patient arrival time to the blood collection time,
which is based on the collection time written on the chemistry specimen.
We also monitor the Press Ganey Outpatient survey results to see if we are
meeting our patients’ expectations.
Use of Quality Tools (max points 250):
We used a value stream map to better understand the process and brainstorm the
following possible causes for delays:
 Peak volume days / times
o Phlebotomy staffing levels / schedules
 Supply Shortages
o Draw stations / supplies not standardized
 Differences in Phlebotomist Productivity
o Analysis of variation between work flows
o Removal of ‘waste’ in phlebotomist cycle time
 Impact of scheduling on Wait times
 Developed Phlebotomy Staffing algorithm
o Used to determine staffing needs
 Patient volumes, arrival patterns & draw times per patient
o Used to optimize mix of personnel to staff at each clinic by half hour
o Used to determine hours of operation
We used an Issue Prioritization matrix to identify issues that needed to be
addressed in the PSC work area.
We used the following graph (which includes previous months’ overall trends and
the current month’s daily trends) to monitor the process daily and to identify outlier
times.
% Arrival to Collect TAT Trends - Mays Clinic
100%
50
95%
90%
45
85%
80%
40
75%
70%
35
65%
60%
30
55%
50%
45%
40%
24.6
21.3
19.3
18.218.317.9
35%
15.7
30%
25
22.4
20
16.3
16.3
15.3
14.2
14.0
12.6
25%
20%
16.0
14.814.415.114.814.915.2
14.1
12.5
11.7
11.4
10.710.910.1
9.5
15
8.3 8.0
15%
8.8
8.6
9.6
10
5.9 5.4
10%
5
5%
0
Fe
b
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ar 0
Ap '10
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7
0%
Average (Minutes)
% within 5 minutes
% within 10 minutes
% within 15 minutes
% within 25 minutes
% within 30 minutes
% within 35 minutes
% within 40 minutes
% within 20 minutes
% Arrival to Collect TAT Trends - Clark Clinic
100%
95%
90%
50
45
85%
80%
75%
70%
65%
60%
55%
50%
45%
40%
40
35
30
25
20.7
16.7
16.1
35% 15.3
15.7
15.4
15.2
14.1 13.9
13.8
13.7
13.4
13.3
13.3
30%
12.413.0
11.1 11.4
10.8
25%
20%
15%
19.1
16.515.9
14.0
20
12.112.4
10.8
10.711.1
9.7
8.7
7.8
13.1
7.5
15
8.2 10
6.4
5.2
10%
5%
0%
5
Fe
b
M '1
ar 0
Ap '10
M r '1
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n 0
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'1 ul 12
2 y
to '12
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te
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ed .
Th 8/
u 1
F 8 /2
M ri 8
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Tu 8 /
e 6
8/
7
0
Average (Minutes)
% within 15 minutes
% within 30 minutes
% within 5 minutes
% within 20 minutes
% within 35 minutes
% within 10 minutes
% within 25 minutes
% within 40 minutes
We also monitored the results of the Press Ganey patient survey. This information
was being used to monitor how we were meeting our patient expectations and to
help us make changes to better meet their needs. (See graphs in Interventions)
Interventions (max points 150 includes points for innovation):
Our improvements from the previous and current projects included:
 5S pilot in ACB (01/11)
 Installed Redesigned Sign-in tables (02/11)
 Phlebotomist workflow enhancements (3/11)
 Roll out 5S projects in Clark Clinic completed (4/11)
 Front Desk Standardization (4/11)
 Departmental Super Star board in Clark Clinic (5/11)
 Roll out 5S projects in Mays Clinic (11/11)
 Changed Hours of Operation (12/2011)
o Mays: M-F 6:30a - 7p
==
6a - 6p
o Clark: M-F 6a – 8:30p
==
6a – 7p
o Rotary: Sun-T 5p – 8:30p ==
3:30p – 8:00p
 Minimized patients waiting before clinic opened (12/11)
 Provided more coverage earlier in the day
 Optimized staffing during busier hours
 Promotion of Regional Care Centers
We continue monitoring and posting the daily TAT graph for all staff to view. This
information sharing has encouraged the staff to aim for the goal and continue to
provide excellent care for our patients. Furthermore, the supervisor uses the data
from the next day’s patient appointment load to ensure proper staffing.
We continue to monitor the turn around time in the Mays and Clark Clinics daily
and upload the graphs to an intranet site for review by all team members. This
helps with trending of patient arrival times and allows the staff to monitor exception
days for special causes.
The staffing levels are monitored daily and adjustments are made as needed. The
tool below is available to the staff for assessing the best way to allocate the
available personnel in the clinics.
Results (max points 250):
We have continued to monitor the turnaround times on a daily basis and have seen
a continual decrease in the wait times of our patients at Mays Clinic.
We can now proudly announce to our Administrators that our goal has been met:
The Mays Clinic has achieved:
Mays Clinic Patient Waiting Times
100.0%
26
90.0%
% of Patients
80.0%
70.0%
60.0%
18
15
14
50.0%
40.0%
9
30.0%
20.0%
10.0%
Monthly
Overall Control
Jan'12
Feb '12
Mar '12
April '12
May '12
June '12
July '12
Overall Phase III
Jan '11
Feb '11
Mar 11
April 11
May '11
June '11
Jul '11
Aug '11
Sep '11
Oct '11
Nov '11
Dec '11
Overall Phase II
Aug '10
Sep '10
Oct '10
Nov '10
Dec '10
Overall Phase I
Mar '10
Apr '10
May '10
Jun '10
Jul '10
Overall Baseline
Dec '09
Jan '10
Feb '10
0.0%
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
Average (Minutes)
% within 10 minutes
% within 20 minutes
July 2010 vs. July 2012
= 95% of patients were collected within 20 minutes vs. 70% baseline from July
2010 (36% improvement).
= 70% of patients were collected within 10 minutes vs. 33.2% baseline from July
2010 (112% improvement).
July 2012 vs. Feb 2010
= 95% of patients were collected within 20 minutes vs. 44% Feb 2010 (116%
improvement).
= 70% of patients were collected within 10 minutes vs. 18% Feb 2010 (289%
improvement).
Also, the Clark Clinic has sustained and improved upon their improvement results,
as noted in the following graph:
Clark Clinic Patient Waiting Times
100%
22
90%
20
16
70%
14
15
14
13
60%
11
50%
12
10
40%
8
30%
6
Monthly
Overall Control
Jan'12
Feb '12
Mar '12
April '12
May '12
June '12
July '12
Overall Phase III
Jan '11
Feb '11
Mar 11
April 11
May '11
June '11
Jul '11
Aug '11
Sep '11
Oct '11
Nov '11
Dec '11
Overall Phase II
Aug '10
Sep '10
Oct '10
Nov '10
Dec '10
0
Overall Phase I
2
0%
Mar '10
Apr '10
May '10
Jun '10
Jul '10
4
10%
Overall Baseline
20%
Dec '09
Jan '10
Feb '10
% of Patients
18
17
80%
Average (Minutes)
% within 10 minutes
% within 20 minutes
The Clark Clinic has achieved:
July 2010 vs. July 2012
= 87% of patients were collected within 20 minutes vs. 82% baseline from July
2010 (6% improvement).
= 62% of patients were collected within 10 minutes vs.47% baseline from July
2010 (32% improvement).
July 2012 vs. Feb 2010
= 87% of patients were collected within 20 minutes vs. 74% 2010 (18%
improvement).
= 62% of patients were collected within 10 minutes vs. 40% 2010 (55%
improvement).
The total hours per week of patient wait time saved from both clinics (using the
difference in the average times) is 344 hours per week.
Press Ganey results supported the improvements made thru out the project.
Revenue Enhancement /Cost Avoidance / Generalizability (max points 200):
Soft Savings:
 Outlier patients in Mays Clinic with more than 40 minutes from Arrival to
Collect dropped from 4.1% in the baseline to 2% in 2012 (53 patients per
week given their volume of 2,500 patients per week).
 Outlier patients in Clark Clinic with more than 40 minutes from Arrival to
Collect dropped from 1.9% in the baseline to 1.0% in 2012 (a difference of
38 patients per week given their volume of 3,750 patients per week).
 Therefore, 91 fewer patients per week had wait times more than 40 minutes.
Conservatively assuming that only 20% of the combined clinics’ difference of 91
patients with more than a 40 minute wait per week had a cost avoidance of $100
per patient (from a combination of missed / delayed downstream appointments,
utilization of affected equipment, poor productivity of personnel, overtime from
personnel, etc.):
 The soft savings total would be over $94,000 per year.
Conclusions and Next Steps:
We continue to monitor and post daily TAT graph. Our future goals include
modifying the process to support and leverage arm-banding, the Sorian system,
bar-coding of patients at check-in, positive patient ID during collection, and an
automated kiosk for patient self check-in.