phlebotomy practice and quality assessment

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Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth EditionDiana Garza, Kathleen Becan-McBride

CHAPTERCHAPTER

Phlebotomy HandbookBlood Specimen Collection from Basic to Advanced

Phlebotomy Practice and Quality Assessment

1




Chapter Objectives

1. Define phlebotomy and identify health professionals who perform phlebotomy procedures.

2. Identify the importance of phlebotomy procedures to the overall care of the patient.

3. List professional competencies for phlebotomists and key elements of a performance assessment.

4. List members of a health care team who interact with phlebotomists.




Chapter Objectives

5. Describe the roles of clinical laboratory personnel and common laboratory departments/sections.

6. Describe health care settings in which phlebotomy services are routinely performed.

7. Explain components of professionalism and desired character traits for phlebotomists.

8. Describe coping skills that are used for stress in the workplace.




Chapter Objectives

9. List the basic tools used in quality improvement activities and give examples of how a phlebotomist can participate in quality improvement activities.

10.Define the difference between quality improvement and quality control.




Clinical decisions are based on:• Standards of practice• Diagnostic testing (laboratory tests, x-rays, etc.)• Patient’s history• Observation of signs and symptoms

Phlebotomy Practice and Definition





Clinical laboratory test results • Are performed primarily on blood specimens• Give an indication of abnormalities inside the

body• Help health providers in clinical decision making





Definition of Phlebotomy• Derived from the Greek words, phlebo, which

relates to veins, and tomy, which relates to cutting

• Synonomous words are venesection or venisection.

• Definition can be summarized as the incision of a vein for blood letting.





How are laboratory test results used in clinical decisions?

• Diagnostic—are there abnormalities or medical conditions affecting the patient

• Therapeutic—is the correct treatment or therapy being utilized

• Monitoring—is the treatment or therapy effective




Phlebotomy practice• Ranges in scope, depth of detail• Can involve clinical, technical, or clerical

functions

• Settings range from inside laboratory to hospital, clinics, or home health care





Know the members of the health care team

• Learn the specialty and sub-specialty areas of health care and medicine

• Learn about other health care professionals and their roles and responsibilities

• Learn about all areas of the clinical laboratory and their functions

Health Care Settings and Health Care Teams




Table 1-1




Table 1-1 (cont)




Become a professional and mature member of the health care team

• Understand the mission of the organization, goals of the group, or project objectives

• Know skills of team dynamics—active listening, setting group norms, etc.

• Understand relevance and commitment to team goals






• Show reliability and dependability in your work • Actively and respectfully participate in

decisions• Learn to be flexible• Manage conflicts in a constructive manner






• Contribute to the cohesion of the team• Contribute to problem solving strategies• Support and encourage other team members





• Clinical pathology: blood and other types of body fluids (and some tissues) are analyzed.– Examples: Blood, urine, sputum, synovial

fluid, CSF, skin scrapings

The Clinical Laboratory and Specimen Collection Services




• Anatomical pathology: autopsies are performed, histologic and cytologic procedures are performed on tissues and fluid specimens, surgical biopsies are analyzed.





Figure 1-1 Example of an Organizational Chart for a Clinical Laboratory




Figure 1-2 The Clinical Laboratory’s Workflow Pathway




Agencies that oversee clinical laboratories• U.S. Food and Drug Administration (FDA)• Centers for Medicare and Medicaid Services

(CMS)– Clinical Laboratory Improvement Amendments (CLIA)

• Occupational Safety and Health Administration (OSHA)

• U.S. Department of Transportation (DOT)





Agencies that oversee clinical laboratories• The Joint Commission• College of American Pathologists (CAP)• International Association of Blood Banks (IABB)• Other credentialing agencies are involved in

certifying and/or licensing laboratory personnel.





Clinical Laboratory Departments• Administrative Office• Supervisory/management personnel• Physicians or scientists overseeing specific

areas of the clinical laboratory• Technical experts and staff perform tests and

report results





Clinical Laboratory Personnel• Pathologists and/or PhD specialists• Administrative/Management staff• Technical supervisors or specialists• Clinical Laboratory ScientistsorMedical

Technologists





Clinical Laboratory Personnel• Medical Technicians or Clinical Laboratory

Technicians

• Medical Assistants

• Phlebotomists





Clinical Laboratory Personnel• Other personnel involved in the clinical

laboratory-laboratory information operators/programmers, clerical staff, quality management staff, safety and infection control staff, biomedical equipment specialists, etc.





Phlebotomy Education & Certification• High school diploma or equivalent• Length of training ranges from a few weeks to

months• Pass a national certification examination• Attend continuing education (CE) programs

Competencies, Certification, and Professionalism for Phlebotomists




Table 1-2




Clinical Duties for Phlebotomists• Identify patients correctly• Assess patients prior to specimen collection

procedures• Prepare patients accordingly• Perform specimen collection procedures





Clinical Duties for Phlebotomists• Collect blood specimens into the correct

containers/tubes• Label blood specimen tubes at the bedside• Assess the degree of discomfort, pain, or

bleeding• Assess the patient after the specimen collection

procedure





Technical Duties for Phlebotomists • Manipulate small objects, tubes, needles• Select and use appropriate equipment• Perform quality control functions





Technical Duties for Phlebotomists• Transport specimens correctly• Prepare/process the specimen for

testing/analysis• Assist in laboratory testing procedures as

needed





Clerical duties for phlebotomists • Print/distribute laboratory requisitions and/or

reports• Answer the telephone• Answer all queries appropriately• Demonstrate courtesy in all patient encounters• Respect privacy and confidentiality





Respect• Confidentiality• Coworkers• Courteous behaviors• Tolerance of differences• Effective communication





Service• Shift focus from oneself to others• Commitment to one’s job duties






Support• Follow organizational policies/procedures• Maintain clean work space• Report errors or damaged equipment/supplies• Respectfully disagree





Growth• Learn more about your job• Learn more about other aspects of your

organization




Figure 1-3 Picture of Professionalism




• Professional Organizations for Phlebotomists– American Society for Clinical Pathology– National Phlebotomy Association– American Society for Clinical Laboratory

Science– National Healthcareer Association– Many others as well…





Table 1-3




Table 1-4




Table 1-4 (cont)




Ethical Standards for Phlebotomists• Do no harm intentionally• Perform according to sound technical ability and

good judgment

• Respect patients’ rights – Confidentiality and privacy– Right to know about their treatment– Right to refuse treatment





Character Traits for Phlebotomists• Sincerity and compassion • Emotional stability and maturity

• Accountability for doing things right





Character Traits for Phlebotomists• Dedication to high standards of performance

and precision• Respect for patients’ dignity, privacy,

confidentiality, and the right to know • Propensity for cleanliness





Character Traits for Phlebotomists• Pride, satisfaction, and self-fulfillment in the job • Working with team members • Enjoy communicating with patients





• Appearance, Grooming, and Physical Fitness– Posture– Grooming and personal hygiene– Personal protective equipment (PPE)– Dress code





Figure 1-4 Keeping a Healthy Mind and Body




Tips for Dealing with Stress• Find time for privacy and relaxation• Associate with gentle people• Seek humor• Exercise (target at least 30 min/day)





Tips for Dealing with Stress• Nutrition and vitamins• Hobbies and social activities• Balanced schedule• Journal writing






Tips for Dealing with Stress• Reading• Avoid harmful habits (smoking, alcohol or drug

abuse)• Seek assistance when needed




Quality Improvement and Assessment

Perceptions of Quality• CLSI—“degree to which a set of inherent

characteristics fulfills requirements”• Others—“excellence,” “high standards,” or

“superiority”• Categories of quality—“scientific or technical”

and “nontechnical or interpersonal”





Quality in health care uses three major concepts

• Efficacy—the health care services provided have a positive impact on the patient’s health, that is, the patient improves or gets well.

• Appropriateness—procedures performed on the patient are the correct ones for that particular condition or illness.





Quality in health care uses three major concepts

• Caring functions—services provided to the patient are available, timely, effective, safe, efficient, respectful, and sensitive to the patient’s needs.




Stakeholders/Customers• External stakeholders are individuals or groups

outside the organization.• Internal stakeholders are individuals or groups

within a health care organization itself.





Quality Initiatives• Standards of practice—CLSI• Educational programs—NAACLS• Certification and licensure—ASCP, NPA, etc• Advocacy groups—ASCP, ASCLS





Quality Initiatives• Code of ethics• Job competencies• Continuing education





QI Models• Different approaches to quality management

and assessment• Six Sigma: data-driven; define, measure,

analyze, improve, control (DMAIC)• Lean Six Sigma: also incorporates speed,

efficiency, quick action• CLSI: 12 Quality System Essentials (QSE)





Quality improvement efforts involve• Health care worker’s technique• Patient identification procedures• Waiting times, turn around times• Complications due to blood collection





Quality improvement efforts might focus on• Multiple sticks on the same patient• Duplicate test orders• Customer satisfaction





Negative impacts (usually preventable)

• Misidentification of a patient

• Hospital-acquired infections due to poor cleansing techniques

• Poor venipuncture technique that causes pain, nerve damage

• Lengthy waiting time, rude behavior, or messy work sites





Tools for Quality Performance Assessment• Reviewing the analytic and nonanalytic parts of

the laboratory – Check sheets– Flow-charts or process maps – Run charts– Statistical tests





Tools for Quality Performance Assessment• Analytically, clinical laboratory scientists and

technicians use data collection to ensure – Test sensitivity– Specificity– Precision and accuracy





Tools for Quality Performance Assessment• Nonanalytic data can be used to assess the

timeliness of responses to – Requests– Turnaround time for reporting test results– Effective communication





Tools for Quality Performance Assessment• Flow charts

– Demonstrate steps in a process– Shows decision points in the process– Provide a pathway to a goal





Figure 1-5 Flow Chart




Tools for Quality Performance Assessment• Pareto charts:

– Bar charts that show frequency of problematic events

• Pareto Principle:– “80% of the trouble comes from 20% of the

problems”





Figure 1-6 Pareto Chart




Tools for Quality Performance Assessment• Cause and effect diagrams • Ishikawa diagram• Demonstrates the factors that contribute to a

specific outcome





Figure 1-7 Cause-and-Effect Diagram




Tools for Quality Performance Assessment• Plan-Do-Check-Act Cycle (PDCA)• Line graphs, histograms, scatter diagrams• Brainstorming






Important Factors Affecting Quality in Specimen Collection Services

• Phases of the Laboratory Testing Process– Preexamination– Examination– Postexamination




Figure 1-8 Laboratory Testing Cycle: Preexamination to Examination to Postexamination




Basic Requirements for a Quality Specimen• Use standard precautions• Identify and assess the patient correctly• Use correct anticoagulants and preservatives • Label, handle, and transport the specimens

appropriately and in a timely manner





Basic Requirements for a Quality Specimen• Correct timing of venipunctures, when necessary• Correct processing of specimens• No more than 2 sticks





Quality Control: A Key Component of Laboratory Quality Assessment

• QC is a part of everyday laboratory practice• QC measures make the testing process more

accurate and precise





QC measures set the parameters for analytical procedures

• Making sure that test results reflect what they are supposed to measure

• Making sure that test results are reproduced time after time





QC measures set the parameters for analytical procedures

• Setting performance standards and acceptable ranges for each test or procedure

• Differentiating which result is OK to report from and which is not OK to report from





Examples of QC• Temperature checks of specimen refrigerators• Calibrations for centrifuges• Positive and negative controls for screening

tests• Monitoring expiration dates for venipuncture

tubes





• Standardization and Globalization (ISO)• Electronic Medical Records (EMR)• Smaller, Faster Laboratory Testing

(nanotechnology)• Direct Access Testing (DAT) or Direct to

Customer (DTC)• Education/Certification

Future Trends in Phlebotomy Practice

phlebotomy practice and quality assessment

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