Getting Started onVenous Thromboembolism (VTE)

Travis DollakImprovement Advisor

WHA

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Today’s Call

1) Our Timeline and Process2) Review Questions from Kick-Off 3) Measures (Q&A)4) Next 30 Days

A. View Science of Safety VideoB. Organizing the Team

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VTE Facts• Pulmonary Embolus resulting from DVT is the most

common cause of preventable hospital death• The risk for developing VTE varies between 10-85%

(depending on reason for admission)• The rate of fatal pulmonary embolus more than

doubles between the ages of 50 and 80

• If Wisconsin prevents 125 DVTs in the next two years we will save our state $1.9 million (~$15K/instance)

http://www.hret-hen.org/images/downloads/508changepacks/vte_change%20package_508.pdf

Initiative Timeline Overview• 9 Month Collaborative• 1-Hr Webinar Each Month – 2nd Wednesday of Each Month 12:00-1:00 PM

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DRIVER DIAGRAM

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DRIVER DIAGRAM continued

Poll Question #1: What have you tried?Which of the following describes your facility best

in terms of progress on this initiative?

a) This is the first time we have worked on it b)We have worked on it in the past but feel we

have regressedc) We have really nailed it and are putting the

finishing touches on the programd)We have all but given up on finding ways to

improve

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Initiative Learning ProcessWebinars

• Review progress of last 30 days• New content• Discussion and sharing• Plan for the next 30 days

Discussion Group• Questions• Peer-to-Peer Sharing

Quality Center• Data submissions• References and Toolkits• Reports (coming soon)

Learning Opportunities

Webinars

Discussion Group

WHA Quality Center

Site Visits

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Theory of Constraints

Reasons Improvement Projects May Have ‘Failed’ in the Past:

•Moved too fast to ‘Protocol and Procedure’ •Did not have the right people involved – engaging frontline staff•Used the same core group of people to fix the problem•Measures were not monitored consistently over time•Did not reinforce training on the new way of doing things•Participants in the initiative do not address the root causes of performance deficiency

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Poll Question #1: ResultsWhich of the following describes your facility best

in terms of progress on this initiative?

a) This is the first time we have worked on it b)We have worked on it in the past but feel we

have regressedc) We have really nailed it and are putting the

finishing touches on the programd)We have all but given up on finding ways to

improve

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How we will overcome the Constraints• Slow down the improvement train• Continuous measurement throughout initiative

(and beyond)• Get the right people involved• Get new people involved• Small tests of change with many front-line staff• Opportunities to revisit training• Focus on project sustainability

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Findings from Kick-Off Meeting

Follow-up from Post-Its on Quality Center Discussion Group• Concerns• Questions• Something to Share

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http://www.whaqualitycenter.org/PartnersforPatients/VenousThromboembolism/VTEDiscussionGroup.aspx

Importance of MeasurementWhy process measures? The purpose of measurement in QI work is

for learning not judgment!

Measures should be used to guide improvement and test changes.

Demonstrate change from a baseline, or initial measurement, and assess the degree of change after an intervention.

I think we improved… but I’m not sure by

how much?

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Outcome Measure: Focus on the customer or patient. What is the end result?

VTE Outcome Measure: Incidence of hospital-acquired VTE (# of VTE per 100 admissions)

VTE Outcome Measure

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VTE Process Measures

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Process Measures: Focus on the workings of the system. Are the parts/steps in the system performing as planned?

VTE Process Measures:Completion of a risk assessment on admission using risk assessment toolOrPrevalence of appropriate prophylaxis (educational, pharmacological, mechanical)

Action Item #1 – Data Submission

Baseline outcome data due June 30th

• Submit via WHA Quality Center Portalo 2011 Data Aggregate (if available) and/oro 2012 Data Monthly (if available)

• Analyze baseline data

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http://www.whaqualitycenter.org/PartnersforPatients/VenousThromboembolism/VTEDataSubmission.aspx

Plan for the Next 30 Days

1. Science of Safety

2. Organizing the Team

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Poll Question #2: Where are you at?

Which of the following best describes your progress on this initiative?

a) Team formed – AIM statement – Held first team meeting -- Analyzing interventions

b) Team formed – AIM Statement -- Held first team meeting

c) Team formed -- AIM Statement d) Team formed e) Just starting

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The Swiss Cheese Model – by James Reason

Science of Safety – How Errors Happen

How Can These Errors Happen?• People are fallible• Medicine is still treated as an art, not a

science• Systems do not catch mistakes before they

reach the patient

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Why do mistakes happen?• Variability based on patient

type• Complexity• Inability to connect risk

assessment with care plan• Human error• Tight time constraints• Inadequate tools (protocols,

policies, supplies)

• Fatigue• Inattention/distraction• Unfamiliar situations/new

problem• Communication errors• Using past solutions

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Process Factors People Factors

Seven Concepts of Patient Safety

# CONCEPT VTE SPECIFIC1 Use-Centered Design (staff

providing care) • Make things visible

Simplified screening tool

2 Avoid Reliance on Memory Vigilance• Provide checklists, flags or alarms as reminders

Use a flow sheet that follows the patient through the transitions of care

3 Involve Patients in Their Care• Teach back

Educate patients and families on risk of bleeding or early signs of VTE

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Seven Concepts of Patient Safety# CONCEPT HAC SPECIFIC4 Anticipate the Unexpected Have pharmacists perform

independent double checks on prophylaxis orders

5 Build in Redundancy• Assume errors will occur and build a system to accommodate

Have pharmacists perform concurrent review of all “opt-outs”

6 Hardcode Your System (process, training, culture)

Utilize frontline clinicians as “first responders” for over/under coagulation

7 Improve Access to Timely Data• Data walls

Make results easily available and visible to all. Post run charts at stations.

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Science of Safety Recipe

• Educate on the Science of Safety• Identify Defects (Staff safety assessment)• Learn from Defects• Implement Teamwork, Communication Tools,

A standardized process

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Action Item # 2 – View Patient Safety Video

Create a roster of who on your team/unit needs to view the Science of Safety video.

http://www.youtube.com/watch?v=GOJJHHm7lnM&feature=results_main&playnext=1&list=PL048D28C888FE3871

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Organizing your TeamConsiderations– Who will you involve?– How will you communication?• Within your team? (notify of meetings)• To others outside of thee team?

– How will you use the webinars? (use as weekly meeting?)

– Identify team structure (key roles, expertise, leaders)– How will you keep everyone engaged?

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Poll Question #2: Results Which of the following best describes your progress

on this initiative?a) Team formed – AIM statement – Held first team

meeting -- Analyzing interventions b)Team formed – AIM Statement -- Held first team

meetingc) Team formed -- AIM Statement d)Team formed e)Just starting

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Action Item #3 - Organizing your TeamOptional Tools to Use

Agenda Team Charter

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Guide to Quality Centerhttp://www.whaqualitycenter.org/

Click Here

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The Next 30 Days

Tools Available On WHA Quality Center:• Science of Safety Video Link• Meeting Agenda (pre-populated)• Team Charter• VTE References and Toolkits

ACTION ITEMSSubmit Baseline Data

View Science of Safety Video

Hold an initiative team meeting

Review Resources in Quality Center

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Questions?

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Reminders:• Please complete the 3 question survey when you

close the webinar window.• Mid-month reminder email• Next Month begin the Model for Improvement