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TQM to the rescue.

The tools of TQM--team building, group problem solving, data-driven decision making, and positive feedback--worked to reverse a blood culture contamination rate in excess of 3%.

HEALTH CARE ORGANIZATIONS--partially at the insistence of regulatory agencies--are incorporating total quality management (TQM) principles into routine operations as a way of improving the quality of patient care and reducing cost.|1-4~ The new paradigm focuses on customer satisfaction and continuous quality improvement through work teams that are entrusted and empowered to participate fully in the problem-solving process.

As just one example, the human resources department at our hospital, a 350-bed, not-for-profit facility in Sioux City, Iowa, introduced the "Making Things Happen" employee empowerment program that incorporates many TQM principles.|5~ Our experience with that program provided us with some of the tools necessary to implement our own TQM project.

Despite some progress, fully breaking down the barriers to implementing TQM will be a slow process.|6~ It takes time to move from the concept of management-directed problem identification and solution to a new culture of empowered, self-directed work teams. Laboratorians are familiar with the statistical tools of TQM but have little experience applying them to systems analysis and improvement. This article describes a pilot project wherein a team used TQM tools to address a quality improvement issue.

* Contamination rate. Our Laboratory Quality Assurance (QAS) Committee had been tracking the blood TABULAR DATA OMITTED contamination rate indicator for over a year when our TQM project began in March 1991. The rate was high (|is greater than~ 3%), physician complaints were increasing, and the estimated cost of patient extended stay and workup was excessive. Despite, or perhaps in spite of, a lot of finger pointing and much discussion at staff meetings, the rate remained conspicuously above the accepted threshold of 3%. The problem with the blood culture contamination rate seemed to be just the issue to try approaching a different way, the TQM way.

* New approach. I was selected to act as the project mentor and facilitator and as such would introduce the TQM project to the QAS committee. I assembled a project team using volunteers from the two sections of the laboratory most directly involved with blood cultures: microbiology and phlebotomy.

* Setting goals. Our first step was to outline the project and establish goals. We already had a consensus that the contamination rate was too high at |is greater than~3%. Our goal was to obtain a contamination rate of |is less than~3%.

The project team met to brainstorm the issue and identify the steps to be taken. Any and all suggestions were open for discussion. The key issues were prioritized and listed in a project timeline. Each key issue was assigned to one of the team members. Dates were established to keep the project moving. Meetings were then scheduled to share progress reports and resolve any unexpected problems.

* Tracking the source. One of the first major issues was trying to find the source of the contamination. The project team identified the familiar, general steps in the blood culture process: enter order, collect specimen, process specimen, read and interpet blood culture, and report results.

We identified specific factors--including people, places, equipment, and situations--that might be contributing to the contamination rate. Our fish bone chart above lists the possibilities.

The phlebotomists on our team next designed a table to be used to track and record the frequency with which incidents of blood culture contamination could be traced to a specific parameter. Team phlebotomists and technologists created a data tracking sheet to be initialed by everyone who collected a blood culture specimen. Figure 3 shows the data and the Pareto chart created from them.

* Phlebotomy problem. Of a total of 84 incidents of blood contamination, 75 were shown to be traceable to phlebotomists. Furthermore, the vast majority of the mistakes were made during venuous collection in the emergency room. The data clearly indicated the need to improve the phlebotomy collection procedure. This became the primary focus of our efforts.

We decided to create a phlebotomy training program that would focus on the issue of blood culture collection. We discussed collection techniques and completed a literature search. Based on it and discussions, the pathologist, the microbiology supervisor, and I then wrote a revised standard aseptic collection procedure.

* Required in-service. We scheduled a mandatory in-service for all phlebotomists. Training was performed by project team phlebotomists, each of whom trained the members of his or her own work group. We found that the improved aseptic collection procedure was accepted more readily when it came from a close coworker. The importance of team building and commitment for improvement was now being recognized by everyone.

As the project continued, we became aware of the need for a clearer definition of contamination. We came to this conclusion after the technologist on the QAS committee submitted a different rate of contamination TABULAR DATA OMITTED than the technologist on the project team. Also, our phlebotomists, who were being challenged for doing the collection incorrectly, pointed out inconsistencies in the definition of contamination.

* New definition. I assigned the drafting of new criteria for blood culture contamination to two medical technologists and the microbiology supervisor from the project team. They conducted a second literature search. Their recommendations were presented to the project team, which used them to write specific criteria for blood culture contamination (Figure 4). We are confident that we successfully implemented the new definition without compromising the validity of our data.

* Visual reminder. In-services and training by the phlebotomists on the project team continued for one month. A progress chart was created and posted in the collection area. This visual display of accomplishment kept the issue on everyone's mind and served to positively reinforce performance as it continued to improve.

Later in the project we began to notice that certain phlebotomists' initials appeared on the data sheets more often than others. One phlebotomist in particular had an unusually high contamination rate. She worked primarily in the emergency outpatient area's Stat lab. I asked her and the other phlebotomists who were in need of retraining to attend one-on-one information-gathering and coaching sessions with the phlebotomy supervisor. This application of TQM's nonthreatening, supportive approach to problem solving allowed the phlebotomists to share freely their work experiences and, ultimately, to improve.

* Emergency room. This acute care area was identified earlier as having a high rate of contamination. Despite our progress, one related problem remains to be solved. After blood has been collected to test for analytes, such as electrolytes or for a cardiac profile, ER nurses sometimes add on blood cultures. This bypassing of aseptic procedures is another interdepartmental issue that TQM techniques may be called on to solve. JCAHO, in its guidelines and agenda for change, is moving exactly in that direction.|2~

Our blood culture contamination project demonstrates how effective cooperating for change can be. Well before the project ended in September 1991, we attained our goal of a contamination rate under 3%. A year later we remained on target.

* Consensus approach. Which methods worked best for us? Among the most important factors were creating a simple step-by-step process (the timeline), assigning responsibility (ownership), group problem solving (consensus and team building), data-driven decision making (TQM tools), and positive feedback.

A threat-free environment, with a consensus for quality improvement, facilitates collaboration and teamwork and results in more creative and effective solutions. It is important to resist the tendency to solve every issue quickly. Move slowly, allowing the group time to come to its own conclusions and create its own solutions.

* Clear visions. As the culture of the workplace changes, managers must learn to establish clear visions and goals more than ever before.|7-9~ Communication with employees must be consistent and devoid of conflicting messages.

Managers must learn to use TQM group problem-solving tools, both the ones mentioned and other such valuable methods as quality control charting. These techniques and their use in data-driven decision making will become familiar concepts in the laboratory in the future.

Figure 4

St. Luke's new definition of blood culture contamination


* Staphylococcus epidermidis

* Alpha streptococci (not S. pneumoniae or enterococci)

* Bacillus species (not B. anthracis)

* Diphtheroids

* Anaerobic propionibacteria

Organisms are considered contaminants when:

* A single bottle or single set of bottles are drawn and are positive with one of the above organisms.

* One set of bottles out of two or more sets collected is positive with one of the above organisms. In the aforementioned set, either or both bottles can be positive to qualify as contaminated.


* Groshongs and Hickmans. Above organisms will not be considered contaminants when isolated from these sites unless physician considers them as such.

* Physician considers organism to be a pathogen and requests susceptibility.

* At the author's hospital, one physician has a standing order that one bottle be drawn and that positive cultures be considered contaminants if one of the above organisms is isolated. This physician requires susceptibilities on all positives, whether or not they are contaminants.


1. Total quality management in health care, Module 2: Implementing total quality. |Seminar~. Curtin Matheson Scientific, Inc; 1990.

2. Joint Commission on Accreditation of Healthcare Organizations. 1992 Accreditation Manual for Hospitals. Oakbrook Terrace, Ill: JCAHO; 1991.

3. Simpson KN, Kaluzny AD, McLaughlin CP. Total quality and the management of laboratories. Clin Lab Management Rev. 1991; 5(6): 448-462.

4. Westgard JO, Barry PL, Tomar RH. Implementing total quality management (TQM) in health-care laboratories. Clin Lab Management Rev. 1991; 5(5): 353-370.

5. Biorn DO, ed. Making Things Happen! Excellence through Empowerment. Las Altos, Calif: Crisp Publications; 1991.

6. American Hospital Association. Continuous Quality Improvement: Can It Work In Hospitals? |videotape 169603~. Chicago, Ill: AHA; 1992.

7. Randolph WA, Posner BZ. Getting the Job Done: Managing Project Teams and the Task Forces for Success. Englewood Cliffs, NJ: Prentice-Hall; 1992

8. Wellins RS, Byham WC, Wilson JM. Empowered Teams: Creating Self-Directed Work Groups That Improve Quality, Productivity, and Participation. San Francisco, Calif: Jossey-Bass; 1991.

9. American Hospital Association. Getting Ready for Continuous Quality Improvement: Fundamentals for Department Managers |videotape 001660~. Chicago, Ill: AHA; 1991.

The author is manager of the laboratory service program at St. Luke's Regional Medical Center, Sioux City, Iowa.
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Title Annotation:total quality management
Author:Lumphrey, Dennis
Publication:Medical Laboratory Observer
Date:May 1, 1993
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