How collaboration = quality in maintaining POCT and phlebotomy programs.

Adaptation has always been the key to survival. Our institution, Lovelace Healthcare Systems, is a large, statewide "staff model" health maintenance organization that includes a 235-bed hospital. A staff model HMO employs its own healthcare workers to provide care to enrollees. Several years ago, we began to realize that we all had to work together to improve the quality of care for our patients and to reduce the cost of that care if our institution was to survive the fierce managed care competition in the healthcare community.

Collaboration between the laboratory and nursing services allowed us to integrate the cross-training and maintenance of ancillary or point-of-care testing (POCT) and phlebotomy programs on the individual units. As is sometimes the case, steps such as these first appear as though the laboratory is giving up some of its "turf," or that the nursing staff is being given one more task to perform. However, this experience has been productive for the organization, supported high quality patient care, and expanded our knowledge and practice beyond the more traditional avenues of nursing and laboratory practice.

Today, we look at POCT and phlebotomy cross-training in a new way. Some of the questions we asked ourselves include: Will POCT improve monitoring and treatment of patients? Is the quality of test results equal to that in the laboratory? Will it reduce the cost of patient care to the institution as it relates to the patient's length of stay, fewer retests, etc? If the answer to these questions is yes, the laboratory says, "Go for it!"

The POCT training program

In early 1990, the laboratory position of ancillary testing coordinator (ATC) was created to organize and monitor POCT. At the time the POCT program was created, most tests performed outside of the laboratory were capillary glucoses, hemoccults, urine dipsticks, and several microscopic tests.

The program today includes 20 different tests performed in approximately 65 locations (at the bedside, in the hospital, and in physician offices) around the state. We also contract statewide with more than 1500 providers. The benefits of our POCT program include (1) the ability to bring more testing procedures in-house without increasing the lab staff and (2) reengineering ideas that have permitted the laboratorians to be more efficient.

Quality of testing. Testing outside of the laboratory is not (and probably never will be) performed exactly the same as testing inside the laboratory. That is not to say that the same quality of testing cannot be achieved in both places, but only that the means to accomplish that quality can be quite different. In our case, the ATC worked closely with the nursing education department to establish a program that continually evaluates the training and credentialing of nursing staff who perform the testing. It is the ATC's responsibility to study and interpret new regulations so that the tasks necessary to the project can be identified. Then the educators can decide the best way to get it done on their units.

Lovelace Health Systems Nursing Services developed a practice standards program in 1988 that included guidelines for both structure (policy) and process (protocol/procedure). As a component of this program, a competency-based orientation for new hires was developed, which requires the orientee to demonstrate competence in areas of both knowledge and skill. Demonstration of competence can take the form of written tests, oral tests, and completion of performance checklists. The orientee must demonstrate the ability to perform skills and manage patient care according to the standards of practice outlined by Lovelace Health Systems Nursing Services. Performance checklists were developed as tools to document competent skill performance by RNs, LPNs, or assisting personnel.

Figure 1

Performance checklist for glucose meter

Name/Employee #: _____

Date: _____

Activity                                              Demonstrated

1. Match patient ID against physician order

2. Keep meter free from obvious contamination

3. Coding the meter

a. Replace "code key" each time a new lot
of strips is opened

b. Code key must remain in meter until new
lot is opened

c. Press the "power on" button to verify that
the code number in the meter corresponds
to the code number on the vial of strips

4. Enter test strip code as per procedure manual

5. Perform daily quality control

a. Check expiration date of strips and
controls; check test strip code

b. Select "CTRLS" and enter operator ID number

c. Perform Level I and Level II

6. Prepare patient for testing

a. Clean finger/heel with soap and water

b. Use universal precautions

c. Turn meter on; select "PAT"

d. Enter operator ID number and patient ID
number (either manually or with barcode
wand)

e. Insert test strip; lance finger/heel

f. When flashing drop icon appears, obtain
a drop of blood on the yellow target area
(fill area completely)

g. When test is complete, enter comment
code if necessary

7. Document patient result on flow sheet or
ancillary report form; notify provider of
result if necessary

Trainer's signature: _____

The use of the designated glucose meter was the first ancillary testing process to be integrated into nursing orientation as part of the credentials for all newly hired RNs, LPNs, and assisting personnel. Glucose monitoring was selected to be included in general nursing orientation because at the time it was the only ancillary test common to most patient care units and performed by almost every nursing employee. This credentialing process took 60 minutes and included both a lecture and demonstration of the patient testing, quality control, and maintenance of the meter. The training was performed by the ATC and provided standardization of performance testing and documentation of competency. Competency on the part of the new employee was demonstrated through successful completion of a written post-test and return demonstration, in which the employee successfully performed the specific skill in front of an instructor after the instructor first demonstrated the procedure. Completion of these activities is documented on a performance checklist (see Figure 1). This approach proved to be efficient for both laboratory and nursing personnel. This orientation class was the beginning of what was to be a growing collaborative and highly productive relationship between the laboratory and nursing education.

Annual recredentialing. It is not enough that nursing personnel demonstrate competence at the time of hire - competency must be maintained throughout employment. Our annual recredentialing process was developed as a means to document each nursing services employee's continued competence and includes two areas of focus: generic and department-specific knowledge. Generic criteria are common to all personnel regardless of area of practice, including fire safety, electrical safety, bloodborne pathogens, intravenous therapy, and CPR. Department-specific criteria apply to areas of practice that are high risk, low frequency, and new or innovative practice issues. Performance of all ancillary laboratory tests are included in the department-specific portion of the annual recredentialing process.

As a change of pace, the dialysis, nephrology, and endocrinology department staff members, with the assistance of the nursing educators, planned and coordinated an "Annual Recredentialing Fair." The fair was developed as a fun and self-directed way of getting a large number of employees to complete the recredentialing process quickly and efficiently. Numerous self-directed learning stations were developed. Ancillary lab testing was one of the learning stations included in this process.

Posters were developed that reviewed the theory and procedure associated with the designated glucose meter, hemoccult, and urine strip chemistry testing. Performance checklists (see Figure 1) and post-tests were created as tools to evaluate competence. The ATC was present at the learning station as each employee read the poster, successfully completed the post-test, and exhibited a successful return demonstration that was documented on the performance checklist. All documentation was then placed in the employee's education files to document ongoing competence.

As the program has evolved, we increasingly involved staff members in the development of these learning stations. In areas where there are career ladders, the employees at the higher levels act as preceptors. These people are first recredentialed by a designated laboratorian or nurse educator, and then return to their departments to recredential other staff members.

After participating in this fair, the ATC realized that although most people have no trouble with the skill part of testing, they do not necessarily know about important idiosyncrasies that can affect each test they perform. In the physician's office, do they know that a hemoccult must be developed within 14 days of specimen collection? Do they remember that urine dipsticks cannot be dipped and then read 15 minutes later after they have prepared the patient to see the physician? Because laboratory testing is not the main responsibility of non-laboratory staff, these are things that require learning and probably regular reminding.

With this educational need in mind, the ATC created self-review posters that list the procedures and guidelines for all tests performed by the staff. The posters went to each department during its recredentialing month so that the staff members could work with them as time permitted. (It was also a great way to get the staff to actually read the procedure!) The written tests were turned in and became part of the recredentialing packet. The requirement is that everyone score at least 80%, just as on proficiency tests. If that is not achieved, remedial training is initiated. On our last Joint Commission on Accreditation of Healthcare Organizations/Clinical Laboratory Improvement Amendments survey, this knowledge testing was an important component of our review.

The laboratory has been monitoring compliance with regulations for POCT since the beginning of the program. The quality control review results are presented in a monthly performance report (see Figure 2) sent from the ATC to each director or manager responsible for the success or failure of POCT for his or her respective unit.

Healthcare reengineering

The established success of the POCT program made the next large initiative at Lovelace Health Systems in 1995 an easier transition. The objective was to redesign patient care services by reorganizing in a way that would continue to provide quality healthcare and a high standard of customer service while increasing efficiency and cost effectiveness. Sound familiar? We began by looking at the patient centered care (PCC) models. in these models, hospital resources and personnel are organized around patients rather than specialized departments. The purpose is to put as many services as possible close to the patient. Goals include increased staff productivity, improved patient outcomes, increased patient and family participation, and decreased fragmentation of care between departments.

Our team of nurse educators was asked to research PCC and to present its findings to a multidisciplinary group of management and administrative staff members. The concept of cross-training the inpatient staff for skills such as respiratory care, laboratory services, and physical therapy to the in-patient staff was met with mixed reviews. Some people within nursing felt they were being asked to do too much and would sacrifice quality of care. Some people from disciplines outside of nursing felt that the nursing staff would not have enough experience and adequate opportunity to perform newly learned skills, and would therefore be unable to remain competent. Everyone was worried about how these changes would affect his or her job.

Despite the concerns expressed, the multidisciplinary team led by the nursing services administrator began meeting to examine the PCC approach more closely. The laboratory was represented by the ATC. She expressed interest in the idea of PCC and began looking at how the laboratory could contribute to the improvement process. Which lab services might be appropriate to transfer to the nursing staff on the patient care units? Although we were not able to completely integrate the PCC concept, the decision was made to transfer performance of in-patient phlebotomy to nursing services.

Phlebotomy moves to nursing. As soon as the proposal to include inpatient phlebotomy as part of nursing services was accepted, the laboratory began to develop a training program. The available time to get the program up and moving was limited to three months.

The ATC and the laboratory specimen collection manager worked together in developing the training program. They developed a 1-day program where the morning was devoted to didactic lessons and the afternoon was a hands,on session. The didactic piece included an introduction to the phlebotomy tools, videos on venipuncture and microcollection, the importance of unique labeling for blood bank specimens, blood culture procedure, and a review of those specimens with special handling instructions. Particular emphasis was placed on the labeling of specimens and the possible consequences of not following the procedure.

In the afternoon, trainees were divided into small groups with a laboratorian as a preceptor where they practiced four skills: (1) microcollection, (2) venipuncture done on an IV arm, (3) a simulated blood culture process, and (4) venipuncture done on a fellow classmate. No one completed the afternoon without performing a successful venipuncture. The feedback from the participants reinforced the class effectiveness.

From there, each participant who had not drawn blood before was required to sign up for time in the laboratory to practice performing more venipunctures. After the completion of a predetermined number of successful venipunctures, each participant was declared to be competent and went back to the unit to begin drawing blood on their own. RNs were encouraged but not required to spend the time in the laboratory because it was expected that they already knew how-to draw blood. However, as we began the training classes, many nurses did choose to participate in the hands-on sessions to become more comfortable with the process.

Results and staff realignment One of the conditions of moving phlebotomy to nursing services was that we needed measurable standards to track performance. In the beginning, we focused on the number and percentage of venipunctures performed by each nursing unit as well as what redraws were necessary. Six months into the transition, we focused more closely on redraws, reviewing how many and what types of redraws were necessary. With that information, we were able to review the process for each department based on where the problems occurred. Now, the goal is to perform 95% of phlebotomies with fewer than 9/1,000 redraws. To monitor the safety of the process for our employees, we also track the number of needle-stick exposures monthly as a result of venipunctures performed by the nursing staff. We are monitoring this against the national benchmark of 12.5/100,000 procedures.[1]

There was skepticism on both sides. Nursing staff members felt that this was just one more task they were asked to perform. The phlebotomists knew that this transfer of services meant that a large part of their job responsibility was being removed. Plus, with this change, we would reduce our phlebotomy staff by one-third. This staff reduction may not sound like a large cut in expenses; however, because only 20% of the laboratory workload is associated with hospital patients, this move was substantial. With the attrition of some employees and the decision of other employees to transfer, ultimately there were no employees laid off. In fact, by the time the process was completed, we found ourselves with fewer FTEs than what we had decided would be ideal.

With this new process, several jobs were transferred to the specimen processing area, which created new positions on what we call the "hotline." Hotline lab assistants act as advisors for the nursing staff, are available for backup during difficult draws, place the orders for tests into the lab computer system, and process the specimens for testing. They play an active role on the trauma team as our institution was designated as the only level-two trauma center in New Mexico.

The nursing staff reaped some benefits from the change as well. Most of the employees performing phlebotomy on the hospital units are nurse techs. Attaining this additional skill both increased their value in the healthcare marketplace and enhanced their self-esteem. We also achieved one of the original goals in introducing PCC - to reduce the number of employees to whom each patient was exposed.

After completing the initial training for those on the hospital staff, the number of phlebotomy classes offered was decreased to one per quarter to catch any internal transfers who may have missed the original classes. The issue then became what to do about new employees. We didn't want new staff members waiting 1 to 6 months for a class. These employees had to be ready to perform phlebotomy when they reached their new unit. As often happens, the answer came as a result of resolving an unrelated problem - downsizing.

Combining POCT and phlebotomy skills training

Both the department of nursing education and laboratory management were downsized about the same time, which meant each person had more duties to perform and less time to perform them. To coordinate orientation and recredentialing of the staff under these circumstances, an expanded central nursing orientation program was initiated that would include knowledge-based and skill-based education and testing. As the week-long Clinical Practice Assessment Program was developed, it became clear that this was a wonderful opportunity to incorporate all of the skills for ancillary testing, specimen collection, and phlebotomy required of staff in both the outpatient and inpatient settings. The orientation skills lab was born!

The orientation skills lab is now directed by a registered nurse competent in all of the necessary skills. Poster sessions for each component, video presentations, lectures, and performance demonstrations are all used to teach the knowledge and skill components for each competency. Post-tests and performance checklists (see Figure 1) are used to document each participant's competence. Lab assistants with national certification and several years of experience in phlebotomy participate in the phlebotomy skills section. This participation both enhanced the position of the lab assistant and illustrated the level of collaboration between the laboratory and nursing services.

In addition, all assisting personnel are required to spend additional hours with a preceptor in the outpatient phlebotomy lab to complete competency testing. RNs and LPNs are referred to the phlebotomy lab for additional training based on the performance level demonstrated during the skill component or because of a personal request by the nurse. This has become a popular and well received program. Because of the interactive methodology, the participants have fun and learn not only from the instructors but also from each other. The participants later reported that they felt prepared for real patient care situations.

This process of continuing education remains a collaborative one between nursing education and the laboratory. In fact, laboratory personnel will sometimes fill in for the nursing instructor during vacations or illnesses. Changes are made to the orientation skills lab based on: (1) feedback from participants and department managers, (2) quality management information, and (3) changes in practice and technology.

This collaborative effort has been an exciting and innovative time for us all. After having the opportunity to walk in each others' shoes, we certainly gained a new respect and understanding of each other. We have learned that it is much more efficient and effective to integrate our efforts rather than to look for the same answers independently. In addition, we have discovered that we can draw experience and expertise from each other to create a great product. It has truly been a win-win for us all!

Figure 2

Quality control report for ancillary testing

Month: _____

Unit: _____

Director/Manager: _____

Quality control compliance (Goal 100%):

Capillary glucose _____

Urine chemistry _____

Urine specific gravity _____

HgB A1C _____

Handheld chemistry _____

Activated clotting time _____

Blood oximetry _____

Blood gases _____

Other _____

Comments: _____

Response: _____

Reference

1. Jagger J. Risky procedures, risky devices, risky job. Advances in Exposure Prevention. 1995;1:4-9.

Diane Krienitz is manager, clinical pathology, and June Sutton is nurse educator at Lovelace Health Systems, Albuquerque, NM.