By February 20, 2007 6 Comments Read More →

We Got Gamed

A somewhat recent experience prompted me to re-read portions of Donald Wheeler’s outstanding book, Understanding Variation: The Key to Managing Chaos, with its section on the three ways people can improve a metric or a target (he gives credit to Brian Joiner):

  1. They can work to improve the system
  2. They can distort the system
  3. They can distort the data

I’ve always observed that people are incredibly clever in figuring out how to game a system to their advantage.I’ve seen it (in a very positive and worthwhile way) while observing an outpatient cancer treatment center, where repeat patients learned which appointment slots tend to get delayed the least (patients learning how to NOT waste time waiting for cancer treatment, you can’t argue with that).The patients’ actions aren’t purposely delaying other patients, so nobody is being harmed.

In most cases, though, somebody or some organization is being harmed by more selfish gaming of the system.It’s sometimes easier for people to distort the system or to distort the data in order to get rewards, be it a pat on the back or an annual bonus check.

One time, with a client, we were measuring the batch sizes of specimens being delivered to the laboratory.Batching of specimens (drawing blood from 10-15 patients before sending it to the lab) was a big contributor to “turnaround time” (cycle time) for the lab.We thought we had explained how we wanted specimens delivered in smaller batches, even if that meant it took more time to do the blood draws and specimen collections.We were measuring the size of the batches for a while until somebody tipped us off to the distortion.

Some of the phlebotomists (employees who draw blood) were taking a batch of 12 patients’ specimens and shipping it down to the lab in four sequential batches of 3 patients each.This made the metric look good, but the lab was still essentially getting a batch of 12.How embarrassing, I thought.I was embarrassed that we hadn’t done a better job of explaining “WHY” we needed smaller batches. Since employees were gaming the system, I felt like there was a failure on my part.

Before jumping to the conclusion that people are being malicious or don’t care, I try to stop and think how their actions might be reasonable.Someone on our team said, “maybe they didn’t understand that it was a turnaround time issue, maybe they thought the tube system physically couldn’t handle large batches?”

Rather than beating up on the phlebotomists, here are our next steps:

  • Re-iterate to them WHY we need smaller batches,
  • Explain what “true” small batches really are and how that benefits the patients
  • Change our measurement system so we track not only the sizes of batches that arrive, but who they came from and at what time they arrived (so we can detect “fake small batches”)
  • Emphasize to the phlebotomists that they need to make the extra trips to the tube station to send the smaller batches.We need to make sure that the lab will pay for enough resources to get the job done with the desired cycle time.
  • Do more direct process observations and Standard Work audits to directly see if phlebotomists are following the correct process or not.

One of my own “kaizen” steps for the future will be to “FMEA” a new metric, to think through how people might game or distort the metric so we can avoid that kind of behavior.


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

6 Comments on "We Got Gamed"

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  1. Anonymous says:

    Interesting situation.

    Have you done some direct observation of the blood drawing process to determine why you are getting batches of blood?

    Is there some schduling issue that would prompt them to take all their samples at once? Perhaps they work a whole hallway at the same time, or they wait until after morning rounds so they don’t have a large group of people in a patient’s room at once. Is the system encouraging this batching, beyond control of the phlebotomists?

    Another item that jumps out is: “need to make the extra trips to the tube station”. That doesn’t sound like it makes their jobs easier. Do you really want a skilled phlebotomist to spend more time walking the hallways delivering samples? Makes it easier for the lab to quickly turn around samples, but makes more work for the people on the front lines. Perhaps there is opportunity for a material handler concept to reduce motion waste on the part of your “skilled operators”.

    You mention Standard Work, but have you made sure that the “correct” way is the “easiest” way? Did the people doing the work develop the standard?

    All common reasons for #2 and #3….food for thought….

  2. Mark Graban says:

    Yes, we’ve done direct observation and we’re still discussing this with the phlebotomists. There is enough time for the “extra” trips to the tube station (rather than drawing all patients on the floor before sending the batch down). So, yes, it’s extra work, that walking, but it’s work that management is willing to pay for. It doesn’t make the phlebotomists’ jobs easier, but that can’t be the only criteria to use. Sorry. Making people’s work easier is a good goal, but customer/patient concerns (fast test results) have to win out.

    The batching is most likely to occur during the morning phlebotomy runs that happen BEFORE morning MD rounds, so we can have test results for all patients by a certain time in the morning. This systemic lack of level loading is problematic at every hospital I’ve seen and the idea of level loading would require MD’s to level load their daily rounds, which isn’t happening.

    As for getting material handlers, with no disrespect to phlebotomists, that’s what they are. They obviously have the skill and training for drawing blood, but they are the lowest paid employees related to the lab. Some labs utilize “runners” but that’s usually when they don’t have the tube system automation for transporting tubes.

    You raise good questions. Part of my reason for the post was to admit that we didn’t have a perfect approach to the situation, but we’re trying to improve over time.

  3. Anonymous says:

    Hmmm…

    The Phlebotomist is at the bottom of the heap?…I find that hard to swallow. Aren’t they the ones directly serving the customer…sticking them with a needle in fact? Seems like most of the lab work for routine blood work is automated…and there is no direct customer exposure except reporting accurate results (very important I know).

    I have no idea how blood testing is done, but having recently spent 2 days in the hospital with a new baby that required several blood samples (and by the way 2/3 of them needed to be repeated because of clotting…my son’s feet looked like swiss cheese), I have a hard time accepting that “the lab wins”. However, I can imagine that’s how it goes…but it doesn’t seem right from the customers perspective.

    One thing to consider about material handling is that perhaps it can be done for free. Seems like phlebotomists are on the move throughout the hospital, with a card that has all their supplies. I imagine they do not let this cart out of their sight. So any trip to the tube probably has the cart with it.

    On the other hand, there is a nursing staff on each floor that is based there, and makes many trips back and forth with little or nothing in their hands. Perhaps a simple visual system could be developed where a Nurse could drop off the samples at the tube as they are walking by. So simple it is no extra work, and they have a stake in getting the blood work back fast because they are the ones the Doc is going to ask.

    That allows the phlebotomist can do what they should…use their time taking good sample and keeping their customers (who are getting stuck with needles) happy.

    In any case, if this batching is still happening, there is probably a good reason(s). And it is probably not “they just need to do their job”, which people always seem to think is the answer. It’s usually the system…and that can be fixed.

    Genchi Phlebutsu if you know what I mean…sounds like the people at each end of the tube need to meet and walk in eachothers shoes more often! The answer is there waiting to be discovered…

  4. Mark Graban says:

    Thanks for the comment. Yes, the phlebotomists do have a rolling cart or a tray that they keep with them. You are right in that assumption. One thing we did to support the phlebotomists was involving them to design a standardized cart that held enough supplies so that they didn’t have to make extra trips to the lab to restock (avoiding waste, making things easier for them, and reducing delays in getting patient draws done).

    I’m not saying that it’s “right” that phlebotomists are the low people in the lab structure, but that’s how it’s been at every hospital I’m seen. The good hospitals will pay phlebotomists a bit more to reduce turnover and will give them training in providing good customer service and patient care (being caring and not just stabbing you with a needle).

    As far as “the lab wins,” I’m not sure of your definition of that. Getting specimens to the lab faster gets your MD the results faster, which improves your care. The patient wins. Consider the common pre-lean alternative of getting your blood drawn and having it carried around for over an hour before it gets to the lab.

    We didn’t, in our project, immediately jump to “single piece flow.” We did consider tradeoffs (and have continued to do so). The phlebotomists do true “single piece flow” later in the day when workloads are lower. The phlebotomists are very very very busy for a three to four stretch in the morning, then things get easier. Sure, we’d love to level load their work, but it’s more practical to make sure the staffing and shift patterns match up with demand.

    As for the repeated draws… I’m not an expert on this, but clotting is normally blamed on lack of skill or lack of care on the part of the person doing the draw (a nurse or a phlebotomist). One thing we emphasize is that phlebotomists shouldn’t rush through their draws or patient care. We analyze how many draws they should be able to do per hour (including walking time), but we never encourage management to “punish” phlebotomists who are slow (there are problem-solving oppportunities to be found there).

    Having nurses “material handle” is an interesting idea, but that would be tough politically as RN’s are paid about 4x a phlebotomist and they are already overworked (60-70% of that work is muda that we should eliminate). If you eliminate RN waste, maybe they could take on some of that material handling, but they’ll complain that you’re distracting them from patient care.

    I don’t mean to poo-poo your suggestions. You’re right, it requires communication and “gemba” and we’re working on improving all of that and have made some progress.

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