BUSI 611 Week 7 Discussion Board Forum 7 Example

Discussion Board Forum 7: Quality Management and Six Sigma

BUSI 611 Operations Management for Health Organizations, Discussion Board Forum 7

Thread by [Student Name]

The emergency department, its laboratory data and the classmates are composites; the textbook, Scripture and the peer-reviewed sources cited are real.

In our 52-bed emergency department, 8.6% of blood samples sent to the laboratory last quarter were hemolyzed, meaning red cells ruptured during collection and released potassium and other contents that falsify results. Every hemolyzed sample must be drawn again. For a patient with chest pain waiting on a troponin result, or a septic patient waiting on lactate and potassium, the redraw adds about an hour to the workup, a second needle stick and sometimes a longer stay in a crowded department. Our laboratory director estimated that redraws consumed more than 1,200 nursing and technician hours a year. Leaders had tried reminding staff to be careful, without change. I proposed treating hemolysis as a quality defect and attacking it with a structured improvement method.

Langabeer and Helton (2016) present Six Sigma as a disciplined, numbers-first way to shrink variation and defects, worked through in a fixed sequence that runs from defining the defect to controlling the fix, and they stress that improvement depends on finding root causes before choosing solutions. In the define phase, our team stated the defect as any sample flagged as hemolyzed by the laboratory analyzer and set a goal of 2% within six months. In the measure phase, we pulled three months of data and broke the rate down by collection method, staff role, shift and tube type. The breakdown was revealing: samples drawn through a newly placed intravenous catheter made up most of the hemolyzed specimens, and rates were highest on the evening shift, when the department is busiest.

Research confirms what our data suggested. Lowe et al. (2008) ran a crossover study at a community teaching hospital emergency department in which 11 experienced nurses, after standardized retraining, collected samples first by one method and then the other. Of 853 samples, 5.6% of those drawn through intravenous catheters hemolyzed, compared with 0.3% of venipuncture samples. The other study shows how far a structured project can go. Damato and Rickard (2015) describe a Lean Six Sigma project at Sarasota Memorial Health Care System, where emergency care center hemolysis averaged 9.8% in late 2009. The team observed practices, compared them with best practices, wrote a housewide collection protocol, standardized processes, built competency-based training and changed emergency department hiring. Emergency care center hemolysis fell 91%, to 0.88%, and housewide hemolysis fell 59%, from 3.4% to 1.39%.

For the improve phase, I recommended that our department draw samples by straight venipuncture whenever a patient does not already need an intravenous line or has easy veins, use smaller-volume or partially filled tubes when drawing from a catheter, retrain every nurse and technician with a competency check and add phlebotomy skill to technician hiring criteria. For the control phase, the laboratory will report hemolysis by staff member and shift every week, with a control chart posted in the break room and a monthly review by the department's quality committee. A staff member whose rate exceeds the target will receive coaching, not discipline.

The control step matters most, because hemolysis tends to drift upward as new staff arrive and old habits return. Orientation for every new nurse and technician will include the collection policy and a supervised competency check before they draw blood alone. A permanent report keeps the measure visible after the project team disbands.

Through the prophet Haggai, God told the returning exiles to consider their ways, because their planting yielded little and their earnings leaked away as if carried in a purse full of holes (English Standard Version Bible, 2001/2016, Haggai 1:5-6). Every redrawn sample is work poured into a bag with holes, and patients pay for it in time and pain.

Reply to Paige

Paige, your thread argued that hemolysis is mainly a training problem and proposed a phlebotomy course for every emergency department technician and nurse. Training is part of the answer, and Langabeer and Helton (2016) describe standard work and staff competence as foundations of quality. Two recent studies show what training can accomplish. Bartolomeo et al. (2026) implemented a phlebotomy training program in an urban academic emergency department, with education for technicians and nurses and knowledge tests before and after. Over the 12 weeks after implementation, the department's troponin hemolysis rate fell from 7.2% to 3.4%, a 56% reduction for samples drawn by technicians and 52% for samples drawn by nurses. Gupta et al. (2021) reported a multidisciplinary project that combined phlebotomy education, competency validation by direct observation, appropriate collection supplies and physician education about proper orders, and the share of rejected blood samples in the emergency department and coronary intensive care unit fell from 1.43% to 0.47%.

Both studies, however, paired training with other changes or measured results over a short period. The Bartolomeo project measured 12 weeks after training, and education effects often fade as staff turn over. The Gupta project included supplies and direct observation, not only classes. Training alone also cannot fix a process that requires drawing blood from catheters, as Lowe et al. (2008) showed that even retrained nurses had far higher hemolysis from catheters than from venipuncture.

I would suggest framing your course as one part of a bundle: training plus a collection-method policy plus ongoing feedback. Competency checks should be repeated yearly and for every new hire, since the department's workforce changes constantly. Measuring each staff member's rate privately would also show who needs coaching, rather than repeating the full course for everyone.

Proverbs asks whether we see a man skillful in his work, who will stand before kings (English Standard Version Bible, 2001/2016, Proverbs 22:29), and phlebotomy is a skill worth honoring and maintaining, not a task anyone can do without practice. A second suggestion concerns who draws the blood. In many emergency departments, nurses draw samples while starting intravenous lines because it saves a stick, which is exactly the practice that raises hemolysis. Assigning dedicated technicians to venipuncture during peak hours, as the Florida project did through its hiring changes, separates the two tasks and lets each be done well. It costs staff time, but the redraws it prevents return much of that time.

Finally, consider sharing results with the staff who draw the samples. When people see their own rate fall after training, the improvement becomes theirs, and they are more likely to keep the habits that produced it. Would your department give technicians protected time each year to refresh their competency?

Reply to Nathan

Nathan, your thread proposed solving hemolysis with equipment rather than people, replacing standard vacuum tubes with low-vacuum tubes and adding a discard tube to every catheter draw. That idea fits the improve phase well, because Langabeer and Helton (2016) emphasize designing processes so that the right result does not depend on perfect human performance. Evidence supports your proposal, with an important limit that shapes how the change should be introduced.

Heiligers-Duckers et al. (2013) tested collection practices at an emergency department where at least 90% of blood was drawn from intravenous catheters. Vacuum collection produced more hemolyzed samples than syringes, 24% compared with 16%. Adding a discard tube lowered the rate to 17%, and low-vacuum tubes lowered it to 12%, both significant improvements. Yet none of the changes brought catheter samples near the 3% rate seen with straight needle venipuncture. Equipment helped, but the collection method remained the largest factor. The Damato and Rickard (2015) project at Sarasota Memorial reached 0.88% only by combining standardized processes, training and hiring changes, not by supplies alone.

Your proposal would therefore work best as one layer of a bundle: low-vacuum tubes and discard tubes for every catheter draw, plus a policy that favors venipuncture when a catheter is not otherwise needed. The tubes add little to the supply budget next to what redraws cost, and the change is easy to sustain because it is built into the supply cart rather than into memory. You might pilot the new tubes on one shift for a month and compare its hemolysis rate with the other shifts before buying them for the whole department.

Ecclesiastes notes that a dull axe forces the worker to swing harder, and that skill is what brings success (English Standard Version Bible, 2001/2016, Ecclesiastes 10:10). Choosing the right tool is a form of wisdom, and so is knowing what a tool cannot do on its own. Supply decisions also involve the laboratory and the purchasing department, not only the emergency department. Low-vacuum tubes may need to be validated for certain tests, and stocking two kinds of tubes risks confusion unless they are clearly labeled and placed in separate bins. A short joint project with the laboratory, in which the lab validates the tubes and the department tracks results, would answer those questions before the switch becomes permanent.

Cost should be part of the pilot report as well. If the new tubes cost a few cents more each but prevent even a small share of redraws, the savings in nursing time and laboratory reruns will likely exceed the added supply cost many times over, and that comparison will persuade the purchasing committee. Has your laboratory measured hemolysis rates separately for samples drawn through catheters and by venipuncture?

References

Bartolomeo, M., Conception, G., Sam, M., Kauari, V., Jackman, K., & Celona, C. A. (2026). Implementing a phlebotomy training program to decrease troponin hemolysis rates in an emergency department. Journal of Emergency Nursing. Advance online publication. https://doi.org/10.1016/j.jen.2026.04.029

Damato, C., & Rickard, D. (2015). Using Lean-Six Sigma to reduce hemolysis in the emergency care center in a collaborative quality improvement project with the hospital laboratory. Joint Commission Journal on Quality and Patient Safety, 41(3), 99-107. https://doi.org/10.1016/S1553-7250(15)41014-1

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Gupta, P., Thomas, M., Sbetan, N., Chacko, G., Savarimuthu, I., Cherian, P., Abas, A., Shiju, S., Karim, S., Kanaan, A., Bautista, G., Elsalasiny, N., Balushi, S. A., Haga, A. E., & Hassan, M. E. (2021). A quality improvement initiative to reduce rejected laboratory samples and enhance specimen acceptability. Joint Commission Journal on Quality and Patient Safety, 47(8), 519-525. https://doi.org/10.1016/j.jcjq.2021.04.005

Heiligers-Duckers, C., Peters, N. A. L. R., van Dijck, J. J. P., Hoeijmakers, J. M. J., & Janssen, M. J. W. (2013). Low vacuum and discard tubes reduce hemolysis in samples drawn from intravenous catheters. Clinical Biochemistry, 46(12), 1142-1144. https://doi.org/10.1016/j.clinbiochem.2013.04.005

Langabeer, J. R., II, & Helton, J. (2016). Health care operations management: A systems perspective (2nd ed.). Jones & Bartlett Learning.

Lowe, G., Stike, R., Pollack, M., Bosley, J., O'Brien, P., Hake, A., Landis, G., Billings, N., Gordon, P., Manzella, S., & Stover, T. (2008). Nursing blood specimen collection techniques and hemolysis rates in an emergency department: Analysis of venipuncture versus intravenous catheter collection techniques. Journal of Emergency Nursing, 34(1), 26-32. https://doi.org/10.1016/j.jen.2007.02.006