System loop analysis eliminates phlebotomy lines

Problem solved by thinking outside the box

Looking beyond the most obvious cause of long lines in phlebotomy has enabled staff at the VA Medical Center in Reno, NV, to eliminate those lines entirely. The key? System loop analysis.

In December 2002, the phlebotomy service relied on a first-come, first-serve process, recalls Stewart Leong, MD, who had at that time just become chief of pathology and laboratory service. "Without a proportional increase in the number of phlebotomists and space, this process had become overwhelmed," he notes.

The problem was initially attributed — albeit erroneously — to a lack of resources. But, not satisfied with that answer, Leong began interviewing the phlebotomists to gain input from the trenches.

Left out of the loop

What he learned was that, to his surprise, every patient had an appointment time. The problem was, the lab didn’t know this.

"We have had what we call Process Action Teams in place for a number of years to address certain problems," he notes. "There had been a team set up to address the scheduling problems a number of years back, but informational resource management people had been making up their own software programs to schedule patients. The initial team was supposed to involve laboratory management, but somehow management was dropped off the team, so they were implementing the process without us."

Leong learned of this disconnect from one of the phlebotomists, who also happened to be one of the patients. "He said that everybody had appointments," Leong says. "When they saw their PCP [primary care physician], they were given a scheduled time to come back and get a blood draw, but for some reason these were not used. And the lab management didn’t know they had an appointment."

Another variable uncovered was a misinterpretation of a Veterans Health Administration mandate relating to disabled vets. "There’s a mandate that they should get priority in getting appointments to see the providers, but that does not mean they have the right to get in line ahead of anybody," Leong explains. "Under first-come, first-serve, there was a line; you can’t come in late and just flash a badge and go to the front of the line. They have a priority in terms of getting an appointment, but not in getting ahead of other people."

Analytical approach

Leong’s analytical approach to the problem unfolded in the following steps:

  • Develop an operational definition of the problem.
  • Identify all important variables and define key variables.
  • Conduct a cause-effect analysis and develop a system loop analysis.
  • Design an improved system.
  • Design the system change management strategy.
  • Implement, evaluate, and record.

The independent variables were identified as: A) service capacity, as defined by speed of service, and B) number of patients. The dependent variables to A were technical factors and system factors; the dependent variables to B were patient population growth, patients’ individual needs, and providers’ needs and expectations. When the loop analysis was conducted, "It became evident that the two independent variables had generated a positive reinforcing feedback loop and overwhelmed the service capacity," says Leong.

Since the current service capacity was a known quantity, the number of patients on the demand side needed to be controlled to correlate with the supply side.

The new system was outlined as follows:

  • The scheduling process successfully set up by Information Resource Management and Primary Care Services was to be incorporated.
  • Patients will scan their identification card at the hospital entrance.
  • Patients will report to the phlebotomy waiting area.
  • Patients will be called to the phlebotomy area when their turn is up on the monitor, by order of appointment time and scanning time.
  • At the phlebotomy area, the patient’s identification card will be scanned again to generate lab test orders and to eliminate their names from the monitor screen.
  • A working "waiting time" of 20 minutes, defined by the time period from scanning in at the hospital front desk to presentation at the phlebotomy area, was set up for monitoring.

"We set up an indicator that we would like to provide service for at least 90% of the people within 20 minutes of their appointment time," says Leong. And how has the new system worked? "For the first seven months, we were way above our goal," he reports.

Need More Information?

For more information, contact:

• Stewart Leong, MD, Chief, Pathology and Laboratory Medicine Service, VA Medical Center, Reno, NV. Telephone: (775) 323-1294. E-mail: