Original article
Using Lean principles to optimise inpatient
1
Department of Pathology,
Clinical Laboratories Division,
Brigham and Women’s
Hospital, Harvard Medical
School, Boston, Massachusetts,
USA
2
Department of Medicine,
Brigham and Women’s
Hospital, Harvard Medical
School, Boston, Massachusetts,
USA
3
Performance Improvement,
Brigham and Women’s
Faulkner Hospital, Boston,
Massachusetts, USA
4
Continuous Improvement
Solutions, UL (Underwriters
Laboratories), Northbrook,
Illinois, USA
5
City of Hope National Medical
Center, Duarte, California, USA
6
Brigham and Women’s
Faulkner Hospital, Boston,
Massachusetts, USA
Correspondence to
Milenko J Tanasijevic, Brigham
and Women’s Hospital, 75
Francis Street, Amory 2,
Boston, MA 02115, USA;
mtanasijevic@partners.org
Received 12 December 2013
Revised 18 April 2014
Accepted 21 April 2014
Published Online First
12 May 2014
To cite: Le RD,
Melanson SEF, Santos KS,
et al. J Clin Pathol
2014;67:724–730.
724
phlebotomy services
Rachel D Le,1,2 Stacy E F Melanson,1 Katherine S Santos,3 Jose D Paredes,4
Jonathan M Baum,1 Ellen M Goonan,1 Joi N Torrence-Hill,5 Michael L Gustafson,6
Milenko J Tanasijevic1
ABSTRACT
Background In the USA, inpatient phlebotomy services
are under constant operational pressure to optimise
workflow, improve timeliness of blood draws, and
decrease error in the context of increasing patient
volume and complexity of work. To date, the principles
of Lean continuous process improvement have been
rarely applied to inpatient phlebotomy.
Aims To optimise supply replenishment and cart
standardisation, communication and workload
management, blood draw process standardisation, and
rounding schedules and assignments using Lean
principles in inpatient phlebotomy services.
Methods We conducted four Lean process
improvement events and implemented a number of
interventions in inpatient phlebotomy over a 9-month
period. We then assessed their impact using three
primary metrics: (1) percentage of phlebotomists drawing
their first patient by 05:30 for 05:00 rounds, (2)
percentage of phlebotomists completing 08:00 rounds by
09:30, and (3) number of errors per 1000 draws.
Results We saw marked increases in the percentage of
phlebotomists drawing their first patient by 05:30, and
the percentage of phlebotomists completing rounds by
09:30 postprocess improvement. A decrease in the
number of errors per 1000 draws was also observed.
Conclusions This study illustrates how continuous
process improvement through Lean can optimise
workflow, improve timeliness, and decrease error in
inpatient phlebotomy. We believe this manuscript adds
to the field of clinical pathology as it can be used as a
guide for other laboratories with similar goals of
optimising workflow, improving timeliness, and
decreasing error, providing examples of interventions and
metrics that can be tailored to specific laboratories with
particular services and resources.
INTRODUCTION
Phlebotomy services are under constant operational
pressure to optimise service while carefully man-
aging cost and resources in the context of increas-
ing volume and complexity of work.1 A joint
report from the College of American Pathologists
and the Center for Disease Control Outcomes
Working Group found that 41% (35 922/88 038)
of errors including donor/recipient misidentifica-
tion, wrong container used for specimen collection,
and specimen mishandling, occurred in the preana-
lytical phase of transfusion medicine,2 highlighting
the importance of upstream quality management.
With errors observed in 0.60% (15 503/2 583 850)
of inpatient tests versus only 0.039% (792/2 032
Le RD, et al. J Clin Pathol 2014;67:724–730. doi:10.1136/jclinpath-2013-202097
133) of outpatient tests in a single year at San
Raffaele Hospital, Bonini et al3 recognised the sig-
nificance of preanalytical errors in inpatients and
speculated that such discrepancy between inpatients
and outpatients is most likely due to the nature of
inpatient testing marked by multiple specimen
drawings and higher test complexity. Additionally,
turnaround time (TAT) for inpatient laboratories
has been shown to be critical for clinicians in order
to improve inpatient management and decrease
length of hospital stay.4 Collectively, these findings
illustrate the importance of a streamlined phlebot-
omy service to minimise TAT and preanalytical
errors in order to improve patient care manage-
ment and satisfaction.
Since the late 1980s, clinical laboratories have
employed Lean principles and tools derived from
the Toyota Production System in order to identify
and eliminate sources of waste and optimise work-
flow. Examples of these tools include kanban cards
(stock supply indicators), spaghetti diagrams (visual
depictions of actual flow), 5S (5 steps of workplace
organisation: sort, set-in-order, shine, standardise,
and sustain), Workouts (single-day, focused events
dedicated to developing action plans) and Kaizens
(multiday, rapid-improvement events involving
frontline staff as experts in process brought
together to identify issues and propose and itera-
tively test solutions in real time in order to improve
overall performance and outcomes).5–10
In many pathology disciplines, the application of
Lean tools has been shown to increase efficiency
and productivity, and decrease TAT and error
without additional resources.6–10 A study con-
ducted by Zarbo et al7 found that the total number
of specimen defects was reduced by 55% after
standardisation of specimen collection and labelling
processes in surgical pathology, while a study by
Raab et al8 observed a 42 min decrease in TAT
after implementation of 200 Lean interventions on
the histopathology section of an anatomical path-
ology laboratory. Likewise, our group has optimised
inpatient phlebotomy staffing using a data-derived
staffing tool9 and reduced the number of mis-
labelled and unlabelled specimens from 5.5 to 3.2
per 10 000 draws through the implementation of
an electronic handheld positive patient identifica-
tion (PPID) device.10
In recent years, Brigham and Women’s Hospital
(BWH) clinical laboratory leadership identified
inpatient phlebotomy as a target for process
improvement in the context of increasing patient
volume, test complexity, and clinician demands for

shorter TAT, particularly during morning rounds when 60% of
our inpatient specimen collections occur. In this study, we con-
ducted three Kaizens and one Workout in inpatient phlebotomy
focused on optimising supply replenishment and cart prepar-
ation and organisation, communication and workload manage-
ment, blood draw process standardisation, and balanced
rounding schedules and assignments. We assessed the impact of
our interventions in conjunction with our efforts to optimise
inpatient staffing9 using three primary outcome metrics: (1) per-
centage of phlebotomists drawing their first patient by 05:30 for
05:00 rounds, (2) percentage of phlebotomists completing
08:00 rounds by 09:30, and (3) number of errors per 1000
draws.
METHODS
Study site
This study was performed at BWH, Boston, Massachusetts,
USA, a large academic medical centre that houses 777 beds
throughout 50 inpatient care units or ‘pods.’ The BWH path-
ology department employs 40 inpatient phlebotomists who
perform approximately 50% of all inpatient draws (about
200 000 venipunctures annually or 600 draws daily) on all
inpatient care units with the exception of the neonatal intensive
care unit. Phlebotomy performs venipunctures on all patients
without central lines (ie, approximately 50%), whereas nursing
is responsible for collection in patients with central lines. Of the
total inpatient phlebotomy draws, roughly 60% (ie, 360 draws
daily) are performed throughout morning rounds (05:00 to
11:00), during which 16–18 inpatient phlebotomists are
assigned to draw patients.
Phlebotomy workflow
The inpatient phlebotomy staff schedule consists of three shifts:
05:00 to 13:30, 13:30 to 24:00 and 24:00 to 08:30.9 Rounds
are conducted at 04:00 (well newborns only), 05:00 (STAT and
discharge rounds), 08:00 (routine morning rounds), 10:00 (add-
itional morning rounds), 12:00, 14:00, 16:00, 19:00, 22:00
and 24:00. Phlebotomist duties from the start to end of a shift
are depicted in figure 1. BWH does not have electronic order
communication between physician order entry and the labora-
tory information system (LIS). Therefore, phlebotomists are
unaware of their workload until they arrive on the pod, review
Figure 1 Typical inpatient phlebotomy workflow with titles, dates and steps targeted for each Kaizen and Workout event.
Le RD, et al. J Clin Pathol 2014;67:724–730. doi:10.1136/jclinpath-2013-202097
Original article
the list of patients to be drawn or ‘pod sheet’, and acquire paper
requisitions containing specific orders for each patient.
Study design
The study occurred in two phases: (1) process improvement
(August 2009–April 2010): completion of three Kaizens (August
2009, October 2009 and February 2010, for supply replenish-
ment and cart standardisation, communication and workload
management, and blood draw process standardisation, respect-
ively), a Workout (April 2010 for rounding schedules and
assignments), and implementation of a new staffing model
(April 2010)9 and (2) postprocess improvement (May 2010–
July 2013): assessment of the cumulative impact of all interven-
tions using three primary outcome metrics as described below.
Though the Workout addressed rounding assignments, we
recognised that a thorough analysis of our current staffing
model was necessary to maximise the benefits of all the other
interventions. The details and impact of the new staffing model,
which was also developed using Lean principles, are addressed
in a previous publication.9 Because the staffing changes were in
close proximity to our Lean improvements, we decided to
include the new staffing model as a part of our process improve-
ment period in this study.
Outcome metrics
The three primary outcome metrics used to gauge the cumula-
tive effect of the Kaizens, Workout, Lean interventions, and
staffing changes were (1) percentage of phlebotomists drawing
their first patient by 05:30 for 05:00 rounds, (2) percentage of
phlebotomists completing 08:00 rounds by 09:30, and (3)
number of errors per 1000 draws, defined to include mislabelled
specimens, unlabelled specimens, incorrect specimen received,
insufficient quantity received, and no specimen received. These
metrics were chosen to span across the entire phlebotomy
process and evaluate quality and efficiency. Goals were set at
80% of phlebotomists to draw their first patient by 05:30 for
05:00 rounds, and at 90% of phlebotomists to complete 08:00
rounds by 09:30. Additionally, we sought to reduce the error
rate to 4 per 1000 draws with no mislabelled and unlabelled
specimens. Data for all three metrics were recorded between
October 2009 and July 2013.
In order to capture first draw times for each phlebotomist,
patient draw times for 05:00 rounds were collected once a week
725
 Original article
from our electronic handheld PPID device (n=195 weeks; 46
months).10 Round completion times were also collected once a
week using manually recorded data by the team leader of when
each phlebotomist checked-in upon completion of 08:00 rounds
(n=195 weeks; 46 months). The median of the percentages for
each week of the month for first draw and round completion
data were determined to yield monthly data. For instance,
recorded percentages of phlebotomists drawing their first
patient by 05:30 for 05:00 rounds in November 2009 were
77% for week 1, 62% for week 2, 83% for week 3, and 54%
for week 4. Thus, the median percentage for November was
determined to be 69%. Lastly, the number of errors per 1000
draws was determined each month (n=46 months). Errors are
generally identified and documented when laboratory staff
compare specimens received with accompanying requisitions,
and determine if the phlebotomist drew and labelled the appro-
priate specimens properly. Error data was compiled by a labora-
tory supervisor.
As a secondary metric, 5S scores for supply cabinet and cart
organisation were determined by a phlebotomist using an audit
tool with a scale from 0 to 15. Results were recorded weekly
(n=195 weeks; 46 months) with the goal of achieving and
maintaining a 5S score above 9.
Statistics
To evaluate the variability and assess stability of the outcome
metrics during and after process improvement, process control
charts were generated. Specifically, P charts were generated for
percentage of phlebotomists drawing their first patient by 05:30
for 05:00 rounds, and completing 08:00 rounds by 09:30 as
appropriate for proportional attribute data with variable sub-
group sizes.11 By contrast, a C chart was created for number of
errors per thousand draws, as the data reports count attribute
data with invariable subgroup sizes.12 Upper and lower control
limits were calculated based on appropriate formulas for the
said process control charts.11 12
Figure 2 P chart of median
percentage of phlebotomists drawing
their first patient by 05:30 for 05:00
rounds. The black line represents the
median percentage of phlebotomists
drawing their first patient by 05:30.
The solid horizontal grey line
represents our goal of 80% of
phlebotomists drawing their first
patient by 05:30. The dashed vertical
grey line separates the process and
postprocess improvement periods. The
dashed horizontal black and grey lines
represent the mean of the median
percentages and lower control limit,
respectively (mean: 53, 78 percentage
meeting criteria during process and
postprocess improvement, respectively).
The date of each Kaizen and Workout
event and implementation of the new
staffing model are also indicated.
726
RESULTS
Outcome metrics
The monthly median percentage of phlebotomists drawing their
first patient by 05:30 for 05:00 rounds noticeably increased
after process improvement (figure 2). We reached our goal of
80% of phlebotomists drawing their first patient by 05:30 for
05:00 rounds in 16 out of 39 months (41%) postprocess
improvement. We also observed only 5 months’ postprocess
improvement in which our percentage was less than 70%.
Figure 3 illustrates a marked improvement in the monthly
median percentage of phlebotomists completing 08:00 rounds
by 09:30 postprocess improvement. We were able to reach our
goal of 90% of phlebotomists completing 08:00 rounds by
09:30 in 36 out of the 39 months’ (92%) postprocess
improvement.
Lastly, the monthly number of errors per 1000 draws
decreased during the postprocess improvement phase (figure 4),
though never reaching our goal of 4 errors per 1000 draws.
However, we recorded 3 months’ postprocess improvement
(February 2011, June 2011, February 2013) in which there
were no mislabelled and unlabelled specimens (figure 5).
Supply replenishment and cart standardisation (Kaizen #1,
August 2009)
Prior to process improvements, frequently and infrequently used
supplies were intermixed and stored in multiple locations (eg,
cabinets, phlebotomy carts, and personal supply bags). Supplies
also lacked labels or visual indicators resulting in inefficient
supply management and expired items. Assessment of 5S scores
prior to process improvement in supply storage areas showed a
baseline score of 6. As a result of Kaizen #1:
▸ 55 lbs (approximately 25 kg) of expired items were removed.
▸ Supplies in cabinets were arranged based on frequency of
use, given a single designated storage location, and clearly
labelled.
▸ A new inventory management system using kanban cards was
implemented to ensure that supplies were always available,
minimise instances of expired items, and visually know when
Le RD, et al. J Clin Pathol 2014;67:724–730. doi:10.1136/jclinpath-2013-202097
 Original article

Figure 3 P chart of median

percentage of phlebotomists
completing 08:00 rounds by 09:30.
The black line represents the median
percentage of phlebotomists
completing 08:00 rounds by 09:30.
The solid horizontal grey line
represents our goal of 90% of
phlebotomists completing 08:00
rounds by 09:30. The dashed vertical
grey line separates the process and
postprocess improvement periods. The
dashed horizontal black and grey lines
represent the mean of the median
percentages and lower control limit,
respectively (mean: 53, 97 percentage
meeting criteria during process and
postprocess improvement, respectively).
The date of each Kaizen and Workout
event and implementation of the new
staffing model are also indicated.

to reorder without the need for counting supplies in
inventory.
▸ All phlebotomy carts were standardised to have the same
layout and specific par levels for each item.
▸ The process of restocking and cleaning the phlebotomy carts
was moved to the end of the shift to increase efficiency at
the start of the shift.
▸ Individual scanners, printers, batteries and carts were
assigned to phlebotomists for each shift to ensure account-
ability and help sustain improvements.
Postprocess improvement 5S scores were greater than or equal
to 9, with the exception of 1 week, and were 15 in the last 25
consecutive weeks of the study (data not shown).
Communication and workload management (Kaizen #2,
October 2009)
Issues identified related to communication and workload man-
agement included the absence of a phlebotomy sign-in/sign-out
system, and the lack of a robust method for communicating
STAT draws during shifts, and remaining draws between shifts.
Such shortcomings resulted in missed draws that spanned shift
change, a delay in STAT blood draws, and complaints from clin-
icians concerning TAT. Communication between phlebotomists
within shifts was also hindered by the limitations of pagers
which required phlebotomists to interrupt workflow to find a
phone, page their colleague, and wait for a return call. After
Kaizen #2:

Figure 4 C chart of number of errors

per 1000 draws. The black line
represents the number of errors per
1000 draws per month. The solid
horizontal grey line represents our goal
of less than 4 errors per 1000 draws.
The dashed vertical grey line separates
the process and postprocess
improvement periods. The dashed
horizontal black and grey lines
represent the mean of the errors per
1000 draws and upper and lower
control limits, respectively (mean: 9.16,
6.64 errors per 1000 draws during
process and postprocess improvement,
respectively). The date of each Kaizen
and Workout event and
implementation of the new staffing
model are also indicated.

Le RD, et al. J Clin Pathol 2014;67:724–730. doi:10.1136/jclinpath-2013-202097 727

 Original article

Figure 5 Number of total

mislabelled and unlabelled specimens.
The black line represents the total
mislabelled and unlabelled specimens
per month. The grey dashed vertical
line separates the process and
postprocess improvement periods. The
date of each Kaizen and Workout
event and implementation of the new
staffing model are also indicated.

▸ A ‘team leader’ was assigned to manage each shift with the
specific responsibilities of tracking, when phlebotomists com-
pleted their assigned rounds, in order to deploy them to
assist other phlebotomists, and supervising STAT requests.
▸ Designated check-in times were established for each round to
monitor the progress of rounds.
▸ A staff communication board was created to allow phleboto-
mists to sign-in/sign-out and indicate remaining draws for the
next shift.
▸ Direct connect phones replaced pagers as the primary form
of communication between phlebotomists, and allowed for
more efficient communication of workflow progress and
complications including STAT draws.
Blood draw process standardisation (Kaizen #3, February
2010)
Prior to our process improvements, the blood draw process was
inconsistent and varied by phlebotomist. Although broader steps
were followed, substeps were often performed in various orders
or omitted altogether, leading to inefficiencies and potential for
error. Other observed habits included batching of requisitions
resulting in bottlenecks in the laboratory specimen processing
area. Spaghetti diagrams showed that phlebotomists had signifi-
cant travel throughout the unit, often retracing their tracks as a
result of the way in which they ordered patients for blood
draws, to retrieve supplies, or to respond to pages. Additionally,
phlebotomists were noted to revert to using a manual process of
labelling specimens despite implementation of the electronic
handheld PPID device. After Kaizen #3, certain steps of the
blood draw process were eliminated, rearranged, and/or desig-
nated to a specific location.
▸ Phlebotomists no longer initialled requisitions or highlighted
pod sheets, as those steps were considered redundant.
▸ Patients were drawn in order of room number and carts were
locked and placed in or near patient rooms to reduce travel.
▸ To assist with implementation and retention, a one-page
visual diagram was created to highlight process safety checks
and aid in remembering frequently missed steps.
▸ A list of exceptions to the standardised blood draw process
was created to ensure that each blood draw situation would
be handled appropriately (eg, precaution rooms).
▸ Labelling specimens using electronic PPID was standardised.
▸ An audit tool was created to measure compliance with the
new standardised blood draw process. All phlebotomists
were systematically trained in the new process over a period
of a month, retrained as necessary, and deemed competent at
least annually.
Rounding schedules and assignments (workout, April 2010)
Prior to and during our process improvement phase, our
inpatient phlebotomists complained about unequal rounding
assignments. This was corroborated by the discrepancy in round
completion times between phlebotomists assigned multiple high-
volume pods, or pods with higher complexity patients versus
phlebotomists assigned relatively low-volume pods, or pods
with lower complexity patients. Several phlebotomists, including
some with many years of experience at BWH, participated in
the Workout. Based on their historical knowledge of patient
volume (ie, number of patients without central lines) and com-
plexity, the Workout team devised a modified rounding schedule
in which assignments were more equally balanced. Pods were
also grouped based on location to allow for efficient travel
between assignments.
DISCUSSION
In this study, we used Lean principles in inpatient phlebotomy
to optimise workflow, increase the timeliness of blood draws,
and decrease error by focusing on supply replenishment and
cart standardisation, communication and workload manage-
ment, blood draw process standardisation, and rounding sche-
dules and assignments. We demonstrated improvement in all
three primary metrics and made a positive impact on the effi-
ciency and accuracy of inpatient phlebotomy services. We illus-
trate the benefits of Lean, and also provide examples of process
improvements that can be implemented and metrics that can be
used to monitor these changes.

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All four process improvement events purposefully targeted
different steps of the phlebotomy process (figure 1), and collect-
ively helped us demonstrate an overall improvement in inpatient
phlebotomy services. Kaizens #1 and #2 were particularly
helpful in making communication between shifts more efficient,
and allowing phlebotomists to begin and end their rounds and
shifts on time, since supplies were organised and ready at the
start of their shift. The Workout helped improve overall round
completion times as redistributing workload between phleboto-
mists allowed for more timely and efficient rounding. Kaizen
#3 was effective at reducing the number of errors and increas-
ing efficiency through removal of unnecessary steps, creation of
memory aids for critical error-prone steps, and implementation
of an audit tool to monitor compliance. Though each Kaizen
and Workout targeted a different step in the inpatient phlebot-
omy workflow, we believe that it is the cumulative effect of all
these changes during the 9-month process improvement period
that improved our metrics. We felt our definition of the process
improvement period was the most accurate way to evaluate a
constantly evolving process involving rotating personnel who
needed time to adapt to workflow changes.
Development of robust metrics and attainable goals is import-
ant in order to continuously monitor progress and sustain
improvement. Though Kaizen #1 was conducted in August
2009, we omitted our data from August 2009 to October 2009
because the metric initially developed was deemed unrealistic.
Our original goal was for 70% of phlebotomists to draw their
first patient by 05:20. However, early data collection showed
that our goal was almost never met largely due to the amount
of travel time required to arrive on the floor. Thus, the metric
was modified during Kaizen #2 to our current goal of 80% of
phlebotomists drawing their first patient by 05:30, allowing for
a more reasonable standard.
The three primary metrics were obtained manually (ie, round
completion times and errors per 1000 draws) and electronically
(ie, first draw times). Though electronic data is ideal since it is
often more accurate and easier to collect, we have shown in this
study that it is possible to establish and sustain manual data col-
lection. It should also be noted that the metrics used to gauge
the impact of the new staffing model (ie, median time of
morning blood draws and average number of safety reports filed
for delayed draws)9 can be useful to other laboratories as well.
Based on qualitative feedback, the process improvement
events also had a positive impact on phlebotomists and labora-
tory staff. Involved staff found the Kaizens and Workout to be
helpful in optimising their own workflow and empowering
them to create change. Additionally, they felt that their experi-
ence was valued by leadership, specifically concerning rounding
schedules and assignments. Phlebotomists generally liked the
new standardised blood draw process and felt that it was safer
and would reduce collection errors. Overall, frontline staff
noted increased satisfaction in the work environment particu-
larly concerning interaction and communication with critical
stakeholders for which they collaborated with on a regular
basis.
There are a number of limitations to our study. With the
exception of anecdotal complaints, we did not have extensive
preprocess improvement metrics that allowed us to gauge the
state of our inpatient phlebotomy services prior to the 9-month
process improvement phase. Additionally, we acknowledge that
statistical analysis would have been helpful to assess the impact
of our interventions. Unfortunately, we were unable to perform
statistical analysis due to the lack of preprocess improvement
data. Lastly, we did not assess the downstream effects of our
Le RD, et al. J Clin Pathol 2014;67:724–730. doi:10.1136/jclinpath-2013-202097
Original article
workflow improvements, such as resultant TAT, or clinician and
patient satisfaction, which would have been helpful to further
illustrate the impact of the interventions hospital-wide.
Despite our efforts, we were unable to meet our ultimate
quantitative goal for number of errors per 1000 draws and are
inconsistently meeting our goals for completion of first patient
draw. We believe this is due to the current lack of order commu-
nication information systems and use of paper requisitions
requiring phlebotomy to continuously perform rounds to deter-
mine which patients are scheduled for blood draws. BWH is in
the process of implementing a new LIS and hospital information
system (HIS) that will enable order communication and elimin-
ate paper requisitions. The new LIS and HIS, including a seam-
less order communication module, should enhance our Lean
efforts to date, and allow us to achieve our goals in the future.
Lean principles can be successfully used to improve processes
in inpatient phlebotomy. Our study can be used as a guide for
other clinical laboratories with similar goals, providing examples
of interventions and metrics that can be tailored to specific
laboratories.
Take home messages
▸ Lean principles can be successfully implemented in inpatient
phlebotomy services to optimise workflow, improve
timeliness of blood draws, and decrease errors.
▸ It is best to target and design interventions for all aspects of
the inpatient phlebotomy service in order to achieve and
sustain success.
▸ Robust metrics should be developed and used to assess
implemented Lean interventions.
Acknowledgements We would like to acknowledge Tanika Patterson, Inpatient
Phlebotomy Supervisor, for her contribution and support in this study. We would
also like to thank all laboratory and phlebotomy staff involved in this study for their
valuable insight, ideas, and commitment to Lean and continuous process
improvement.
Contributors Study design: SEFM, KSS, JDP, JMB, EMG, JNT-H, MLG, MJT. Data
gathering: KSS, JDP, JNT-H. Data review and final review: RDL, SEFM, KSS, JDP,
JMB, EMG, JNT-H, MLG, MJT. Draft article: RDL, SEFM, MJT.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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730 Le RD, et al. J Clin Pathol 2014;67:724–730. doi:10.1136/jclinpath-2013-202097