Clinical Chemistry / Applying Lean to Improve Phlebotomy
Applying Lean/Toyota Production System Principles to
Improve Phlebotomy Patient Satisfaction and Workflow
Stacy E.F. Melanson, MD, PhD,1 Ellen M. Goonan, MS, MT(ASCP)SH,1
Margaret M. Lobo,1 Jonathan M. Baum, MBA,2 José D. Paredes, MS,2 Katherine S. Santos,2
Michael L. Gustafson, MD, MBA,2 and Milenko J. Tanasijevic, MD, MBA1
Key Words: Lean; Phlebotomy; Specimen collection; Process improvement; Clinical laboratories
DOI: 10.1309/AJCP7FIKZVVTFTXQ
CME/SAM
Upon completion of this activity you will be able to:
• describe Lean/Toyota production system principles.
• apply Lean principles to the clinical laboratory.
• discuss how to conduct and monitor Lean process improvement.
Abstract
Our goals were to improve the overall patient
experience and optimize the blood collection
process in outpatient phlebotomy using Lean
principles. Elimination of non–value-added steps and
modifications to operational processes resulted in
increased capacity to handle workload during peak
times without adding staff. The result was a reduction
of average patient wait time from 21 to 5 minutes, with
the goal of drawing blood samples within 10 minutes
of arrival at the phlebotomy station met for 90% of
patients. In addition, patient satisfaction increased
noticeably as assessed by a 5-question survey. The
results have been sustained for 10 months with staff
continuing to make process improvements.
914 Am J Clin Pathol 2009;132:914-919
914 DOI: 10.1309/AJCP7FIKZVVTFTXQ
The ASCP is accredited by the Accreditation Council for Continuing
Medical Education to provide continuing medical education for physicians.
The ASCP designates this educational activity for a maximum of 1 AMA PRA
Category 1 Credit ™ per article. This activity qualifies as an American Board
of Pathology Maintenance of Certification Part II Self-Assessment Module.
The authors of this article and the planning committee members and staff
have no relevant financial relationships with commercial interests to disclose.
Questions appear on p 973. Exam is located at www.ascp.org/ajcpcme.
The health care system in the United States is frequently
criticized for waste, inefficiency, and medical errors.1 To
address these concerns, several institutions have used Lean
principles to improve workflow and capacity and increase
patient and employee satisfaction.2 Lean is derived from the
Toyota Production System, which emphasizes the elimination
of waste and non–value-added steps in a setting of limited
resources, eg, money, space, and human capital.3,4 Kaizen,
which means continuous improvement, events are one method
to apply Lean principles to a process or setting. Occurring
over 4 days, a Kaizen event brings together front-line staff
members, who are experts in the process, to brainstorm issues,
identify solutions, and iteratively test ideas in the work area in
real time. Successful tests are further refined and incorporated
as part of the standard work.
Brigham and Women’s Hospital (Boston, MA) is
a 777-bed teaching affiliate of Harvard Medical School
(Boston) with approximately 46,000 admissions per year and
1 million outpatient visits. The clinical laboratory provides
phlebotomy services for inpatients and outpatients. There are
5 on-site locations for outpatient blood draws. The primary
outpatient phlebotomy area draws samples from an average
of 190 patients and obtains 500 specimens per day during the
week. It is staffed by 8 phlebotomists and operates between
the hours of 7:30 AM and 6:00 PM.
The clinical laboratory leadership selected the main outpa-
tient phlebotomy laboratory to undergo Lean process improve-
ment through a Kaizen event owing to its large volume of
patients and specimens and its direct impact on patient care.
Our objectives were to improve patient satisfaction and reduce
patient wait time. This article outlines the process, details its
impact on workflow and patients, and offers suggestions for
© American Society for Clinical Pathology

laboratories embarking on similar process improvement proj-
ects. This is one of the few articles describing the use of Lean
principles in phlebotomy.
Materials and Methods
Preimplementation Work
With assistance from a group of trained Lean leaders
from the Center for Clinical Excellence (CCE) at Brigham and
Women’s Hospital, we chose outpatient phlebotomy as an area
to apply Lean principles during one of several Kaizen events
conducted in the clinical laboratories. We formed a multi-
disciplinary Process Improvement Leadership Committee
composed of clinical laboratory and CCE staff, all of whom
were given Lean training from GE Healthcare Performance
Solutions (Chalfont St Giles, England). The Leadership
Committee was charged with determining the objectives and
scope for the Kaizen event. Before the process improvement,
we also ensured that other departments, such as information
technology and engineering, would be available to assist in real
time with any technical and operational changes.
An essential element of Lean is the central role of front-
line staff. It reflects the belief that the people directly involved
in the daily work are best equipped to evaluate and determine
what changes are needed. Therefore, appropriate personnel
were selected from existing staff, and schedules were rear-
ranged to allow them to have dedicated involvement in the
process. A timeline and sequence for the process improve-
ment events were defined. Before the actual Kaizen event,
the existing processes were examined from patient arrival to
patient departure from the phlebotomy location. Each stage of
patients’ experience was observed to understand the causes for
delays or prolongation of a patient visit. The following preim-
plementation metrics were collected: patient volume by hour
and day of the week; staffing by hour and day of the week;
and patient wait time. Patient wait time was measured from
8:00 to 11:00 AM during peak hours when the most patients
were seen. In addition, patient satisfaction was assessed using
a 5-question survey that asked about the courtesy and skill
of phlebotomists and the length of their wait. Patients were
instructed to respond to the questions on a 5-point Likert scale
(excellent, very good, good, fair, or poor).
The data were used by the Leadership Committee to
validate and refine the process objectives. The following
goals were set: (1) 50% or greater improvement in patient
survey results for questions regarding the length of the
patients’ wait and how well they were kept informed and (2)
at least a 5-minute reduction in patient wait time, with 90%
of patients waiting no longer than 10 minutes. The leadership
team charged the Kaizen team with applying Lean principles
© American Society for Clinical Pathology
Clinical Chemistry / Original Article
to each of the phlebotomy processes, including eliminating
nonessential work functions, improving the efficiency of
non–blood-drawing activities, reordering process steps, and
changing accessioning workflow. However, the leadership
team placed constraints and asked that minimal additional
resources or expenditures be used and that the caliber of ser-
vice be preserved or improved.
Kaizen Event
A multidisciplinary Kaizen team was chosen to partici-
pate in the 4-day Kaizen event and included 4 phlebotomists,
1 chemistry medical technologist, and 1 laboratory technician.
The Kaizen team was led by the Lean leaders from CCE. Day
1 consisted of a kickoff by the sponsors, review and validation
of improvement opportunities, and education on Lean prin-
ciples. On day 2, the team identified and selected solutions
and developed Plan-Do-Study-Act (PDSA) test plans. The
PDSA method is an iterative testing approach that includes
planning the test, conducting it, observing, and measuring
the results. These plans allowed the team to begin testing and
measurement on day 2. The third and fourth days consisted of
making modifications to the tests as necessary and continued
measurement to study the results. Because testing was taking
place in the live setting, communication and sustain plans
were developed. On the last day of the event, testing and
measurements were completed, standard operating procedures
were updated, and a 30-day action plan was created. At the
end of each day, the team presented its progress to the leader-
ship team members, who gave their feedback and support.
Continuing Improvement
Process improvements continued after the Kaizen event
was concluded, and leaders and front-line staff continued to
use Lean principles under the guidance of Lean leaders as
necessary. The average patient wait time and percentage of
patients meeting the wait time goal were tracked and distrib-
uted to staff weekly. Patient satisfaction surveys were reas-
sessed several months after completion of the Kaizen. Brief
meetings (or “huddles”) were also conducted within the work
area with staff every 2 or 3 days. This allowed participants to
quickly assess how well changes were being sustained and
evaluate if modifications were needed. More formal meetings
were convened weekly for the 30 days immediately following
the event and now continue on a monthly basis. This allowed
staff and management to ensure that all action items from the
Kaizen event were being completed.
Statistics
To evaluate the variability in patient wait after the
Kaizen event and assess whether an improved stable pro-
cess was achieved, process control charts were generated.5-7
Specifically, X-bar and S charts appropriate for continuous
Am J Clin Pathol 2009;132:914-919 915
915 DOI: 10.1309/AJCP7FIKZVVTFTXQ 915
Melanson et al / Applying Lean to Improve Phlebotomy

data with subgroups of variable sizes were created. The X-bar
represents the average patient wait time and the S chart rep-
resents the standard deviation. Upper and lower control limits
were calculated based on 3 σ limits.5-7 Process control charts
allow distinguishing between variation due to common causes
and variation due to special causes. A process is considered
stable when there is “random distribution” of plotted points
within the control limits. Variation due to special causes is
evident when points fall outside the control limits.
Results
Kaizen Prework
The existing workflow was documented ❚Figure 1❚.
The following opportunities were identified during the pre-
work period: (1) Non–blood-drawing activities decreased the
amount of time phlebotomists could devote to their patients.
(2) Patients often arrived before the opening of the phle-
botomy station, creating a backlog at the beginning of the
day that increased wait time. (3) Because patients were not
aware of their “place in line,” staff sometimes had difficulty
identifying and finding the next patient when it was his or her
turn. Before our process improvement initiative in outpatient
phlebotomy, the average patient wait time during a high-
volume period was 21 minutes (± 3 minutes). A pre-Kaizen
patient survey was completed by 34 patients, and an average
of 56% of responses were “excellent” or “very good” ❚Figure
2❚. Patients were least satisfied with being informed about the
wait time and the length of wait.
New Lean Workflow and Kaizen Event
One of the first changes we introduced was a number-
ing system. All patients were given a number indicating their
place in line. Because the number of the last patient called
was clearly displayed, arriving patients would also know how
many people were ahead of them. The sign also showed the

Patient Patient Patient

Accession
Arrives Draw Leaves
• Patient arrives • Test ordered • Drawing
is logged phlebotomist or
• Front desk person front desk person
takes registration card • Label and calls next patient Specimen
and requisition form registration card Processed
are attached to • Patient name
• Patient waits to requisition and and date of birth • Phlebotomist checks tubes,
be called placed in confirmed initials requisition, and places
“ready basket” in bin (by pneumatic tube)
• Blood is drawn
• Person assigned to
pneumatic tube

- Verifies requisition,
specimen tubes, and labels

- Pairs urine with blood drawn

- Periodically sends specimens

❚Figure 1❚ Phlebotomy workflow before Kaizen event and application of Lean principles.
Excellent and Very Good Responses (%)

100 91% 92%

88% 88%
90 85% 85% 85%
82%
77%
80 72%
69%
70 62%
56%
60
50 44% 44%
40
30
20
10
0
Answered Informed About Respect for Length Cleanliness
Questions Wait Times Privacy of Wait and Comfort

❚Figure 2❚ Patient satisfaction survey results. The percentage of patients responding excellent or very good to each of the 5
questions pre-Kaizen (white bars), at the end of the Kaizen (gray bars), and 5 months after the Kaizen (black bars) is plotted.

916 Am J Clin Pathol 2009;132:914-919 © American Society for Clinical Pathology

916 DOI: 10.1309/AJCP7FIKZVVTFTXQ

laboratory hours and the busiest periods so that patients could
return at a slower or more convenient time of their choosing.
We increased phlebotomists’ available draw time by
eliminating non–value-added tasks or modifying existing tasks
❚Table 1❚. Furthermore, to improve efficiency during peak
hours, requisitions for standing orders were copied the night
before patient arrival. Because having every phlebotomist call
his or her own patients into the drawing area was inefficient
and time-consuming, a result of the Kaizen was to have 1
phlebotomist each day assigned as the workflow coordinator
or “greeter.” The workflow coordinator increased efficiency,
greeted the patient to provide a more personalized environment,
and was available throughout the process to answer questions.
In addition to these operational changes, the urine collec-
tion procedure was modified. Before the improvement event,
patients typically provided a urine specimen after having their
blood drawn. However, offering patients the option of produc-
ing a urine specimen while they waited served to decrease
their total time spent in the laboratory. The phlebotomist
workspace was also reorganized to improve workflow. A rep-
resentative from the engineering staff was available to address
any structural questions about the workspace.
Improved Metrics
The average wait time decreased from 21 minutes (± 3
minutes) to 11 minutes (± 5 minutes) for all patients during
the event. The different workflow before the Kaizen event
contributed to long wait times; these may have included
patients arriving without required information such as clini-
cian identification or diagnosis. Collecting urine specimens
before the blood draw helped decrease wait time. For patients
requiring urine collection, the wait time was reduced by 20%.
The percentage of time spent performing non–value-added
tasks decreased, which also contributed to shorter wait times.
Since the Kaizen event, the average wait time has decreased
to less than 5 minutes and has been maintained at this level for
the last 5 months ❚Figure 3❚.
The X-bar chart shows that in the first few months after
the Kaizen event, a number of points fell outside the control
❚Table 1❚
Phlebotomist Non–Draw-Related Activities
Problem Identified
Double-checking specimen before sending
Using log to record when canister was sent via pneumatic tube to laboratory
Using “STAT” or “Rush” stickers on all tubes and bags
Requiring current registration card from patients
Answering phone for general laboratory questions
Calling central transport for specimens that are not transported via pneumatic tube
Patients were unsure of their place in line or the hours of operation
© American Society for Clinical Pathology
Clinical Chemistry / Original Article
limits, which was most likely due to holidays and adjustment
to the new workflow (Figure 3A). Starting on October 20,
the patient wait times shifted downward, and the following
23 consecutive points were below the original lower control
limit. This indicated a special cause variation and an improved
stable process as a result of the Kaizen event, changes in the
staffing model in October, and other workflow changes. The
S chart mirrors the special causes seen on the X-bar chart
(Figure 3B). The charts were redrawn starting October 20
to reflect the new control limits and illustrate 2 distinct pro-
cesses. The new process shows less variability, and the central
tendency is approximately 70% lower (13 to 4 minutes) on the
X-bar and 40% lower (7.02 and 4.28 minutes) on the S chart
compared with the old process. Beginning on February 2,
there was further evidence of the continued downward trend
in both X-bar and S charts.
The level of consistency that phlebotomy achieved also
improved. Following the Kaizen event, the percentage of
patients waiting 10 minutes or fewer varied from as low as
20% to as high as 80%. This variability was due to multiple
factors, such as staffing that did not match patient volumes
throughout the day, break schedules, and hours of operation.
These issues were resolved over time, and during the last 5
months, this percentage has consistently been between 80%
and 90% ❚Figure 4❚. The amount of time it took phlebotomists
to physically collect specimens did not change before and
after the Kaizen event, suggesting that the shorter and more
consistent wait times could be attributed to process improve-
ment and reduction in non–value-added steps.
Patient satisfaction was assessed at the end of the Kaizen
event (n = 50 patients) and 5 months after the Kaizen event
(n = 33 patients). An average of 86% of patients responded
“excellent” or “very good” at the end of the Kaizen event
(Figure 2). In particular, responses to questions regarding
the length of the patients’ wait and how well they were kept
informed improved by approximately 50%, which was consis-
tent with our goal. These results were sustained as illustrated
by the 5-month post-Kaizen survey (Figure 2). In addition
to the patient survey, comments on the new and old process
Solution
Non–value-added task was eliminated
Non–value-added task was eliminated
STAT” or “Rush” stickers were placed only on the
outside bag
Current and expired registrations cards were accepted
A voicemail guiding clinicians was implemented
Scheduled regular central transport pickups to avoid
phone calls
Patient-friendly signs were placed
Am J Clin Pathol 2009;132:914-919 917
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Melanson et al / Applying Lean to Improve Phlebotomy

A
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❚Figure 3❚ A, X-bar process control chart. The average patient wait time for a morning in the beginning of each week (diamonds,
black line) is plotted. Upper (red line) and lower (green line) control limits and the central tendency (dotted black line) are shown.
B, S-chart. The standard deviation of the patient wait times (diamonds, black line) is plotted for each day data were recorded.
Upper (red line) and lower (green line) control limits and the central tendency (dotted black line) are shown.

100

90

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% of Patients

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as
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Kaizen Event

❚Figure 4❚ The percentage of patients meeting the wait-time goal. The goal of 90% of patients waiting 10 minutes or less is
shown by the solid straight line. The percentage of patients achieving this goal for a morning in the beginning of each week is
plotted (diamonds, solid line).

918 Am J Clin Pathol 2009;132:914-919 © American Society for Clinical Pathology

918 DOI: 10.1309/AJCP7FIKZVVTFTXQ

were obtained from staff and patients that illustrated improved
quality and efficiency. Some patient comments after the
Kaizen event were “felt more organized,” “efficient and well
run,” and “liked having a first-come first-served system and
knowing place in line.”
Discussion
In the setting of decreasing availability of technical
staff, complaints about work-related stress, increasing test
menu, and limited space, pathology departments and clini-
cal laboratories are asked to improve turnaround time and
expand services while reducing cost. Lean principles can be
applied to achieve these objectives, and a few organizations
have published their experiences.3,8-12 However, most insti-
tutions focused on specimen processing within the clinical
laboratories.8-12 In particular, they implement a single-piece
workflow, as opposed to batch workflow, to distribute the
workload more evenly. A limited number of articles discuss
the redesign of specimen collection processes to achieve
improvements.9,11 In this article, we describe our experience
and use of Lean principles to improve outpatient phlebotomy
workflow and patient satisfaction.
Our Lean process improvement initiative has shown sig-
nificant and sustained improvement in patient satisfaction and
workflow efficiency in outpatient phlebotomy. Although this
required a significant time commitment from leadership and
staff, all improvements were made without additional staffing
or space and with minimal budget resources.
Successful application of Lean principles has led to addi-
tional improvements since the initial Kaizen event. Several
modifications were made to the staffing model to allow
increased availability of phlebotomists during peak hours
(8:00-11:00 AM). The break schedule was shifted from the
morning to afternoon, and staff schedules were modified to
increase the number of staff working during the first 2 hours
of the morning. In addition, the opening of the laboratory was
moved from 8:00 AM to 7:30 AM to accommodate patients
with early clinic appointments. A rarely used fifth phlebotomy
chair was replaced with one that had similar functionality to
the other chairs to increase drawing capacity by 20%. Finally,
the patient experience was improved by increasing the num-
ber of chairs in the waiting area. These additional changes
contributed to the improved and sustained process that is
illustrated in the process control charts.
Throughout the process we gained several insights
into Lean process improvements that may be helpful to
other hospitals or organizations considering implementa-
tion of Lean. Our experience has illustrated the significant
amount of work and organization that is required for suc-
cess. Changes to the systems and structures, as well as to
© American Society for Clinical Pathology
Clinical Chemistry / Original Article
the culture of the department and institution, must occur to
support improvement work like Lean. It is important to have
management support throughout the process, especially to
empower front-line staff to continually identify opportunities
for improvement and to celebrate the successes of the imple-
mented improvements. We also found it useful to have key
areas of the hospital, such as engineering, available to make
changes in real time.
We continue to use Lean process improvement tech-
niques throughout the department. We have subsequently
completed 3 more Kaizen events in specimen processing and
clinical chemistry. They have also yielded improvements to
operational processes and positively impacted patient care.
The Lean culture has also expanded to other departments,
resulting in improved services hospital-wide.
From the 1Department of Pathology, Clinical Laboratories
Division, and 2Center for Clinical Excellence, Brigham and
Women’s Hospital, Harvard Medical School, Boston, MA.
Address reprint requests to Dr Melanson: Brigham and
Women’s Hospital, 75 Francis St, Amory 2, Boston, MA 02115.
Acknowledgements: We thank the entire Kaizen event team
(Linda Crane, Lidia DeMartino, Yamil Garcia, Nadege Michaud,
Telisha Morris, and Donovan Wallace) for their creative ideas, hard
work, and ongoing commitment to Lean and process improvement.
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