Sharon Mindel, Pharm D Terry Rodgers, RN, MSN Jeannie Ritzius, RN Virtua Health Sharon Mindel, Pharm D Terry Rodgers, RN, MSN Jeannie Ritzius, RN Track1B.Ritzius et al--8.20@2.30pm QC

ST P THE CLOT! TIME IS RUNNING OUT : Track1B.Ritzius et al--8.20@2.30pm QC

Virtua Health Four hospital system in Southern New Jersey Two Long Term Care Facilities Two Home Health Agencies Two Free Standing Surgical Centers (JVs) Two Medical Staffs (currently merging) Ambulatory Care - Camden Fitness Center 7,100 employees + 2000 physicians 7,752 deliveries 8% Operating Margin - #1 in the state of NJ STAR Culture Virtua receives the JCAHO Gold Seal for: Stroke Center at Memorial, Total Joint Program, and Spine Program

More deaths than AIDS, breast cancer and highway fatalities combined DVT + PE = VTE 200,000 – 600,00 reports of VTE in the United States annually contribute to 60,000 – 200,000 deaths per year More deaths than AIDS, breast cancer and highway fatalities combined VTE is preventable Many patients at risk do not receive prophylaxis Track1B.Ritzius et al--8.20@2.30pm QC

Risk of VTE in Hospitalized Patients Patient Group VTE Prevalence, % Medical Patients 50-70% General Surgery 15-40% Stroke 20-50% Hip/Knee Arthroplasty, Fracture 40-80% Major Trauma 50-80% Spinal Cord Injury 60-100% Critical Care Patients 10-33%

Project Title: Standard Practice for Venous Thromboembolism (VTE) Prophylaxis Division (s): Marlton Goal/Opportunity/ Description Statement: To increase clinical quality and patient safety and decrease cost associated with VTE Target 90% of patients identified at risk for VTE will be prophylaxed Sponsor (s): Carol Mullin Process Owner (s): Mary Ann Krug, Sharon Mindel, Terry Rodgers, Dee Page, Sabina Zabrodski, Lynn Block Team Members: Sharon Iannece, Mary Saunders, Jennifer Smith Green Belt: Terry Rodgers Master Black Belt: Donna Forrest Black Belt: Jeannie Ritzius Physician Advisor: Dr. Sutherland  Talk about team dynamics, Interdisciplinary approach, Quality Director as sponsor. Project chosen anticipating a Core measure , looking at issue in surgical patients and it was a matter of time that it would be addressed for medical patients. White paper 2003 by American Public Health Association to increase awareness, to educate public and work with health care policy makers to make it a public health priority  Track1B.Ritzius et al--8.20@2.30pm QC

Measure Phase What is the Right Y to Measure? How will it be measured? Prophylaxis of patients assessed for risk of VTE. Discrete data was used to be measured through chart review of discharged patients. What is a Defect? What are the process specifications? Y1 Defect: Not prophylaxing patients identified at risk for VTE USL = none LSL = none Target = 90% based on Sponsor identified CTQ Data Sources: Medical Records and Net Access 249 Charts manually and electronically Measurement System Accuracy: An SOP was developed 20 charts were gaged Initial gage revealed 90% agreement Repeat gage after review of SOP revealed 95% correct and agreed upon 20 charts were gaged using hard copy Medical Records This gage also had 95% confidence Speak to the gage and data collection. The problem exists due to the focus being on getting patients better and decreasing the LOS. Focus often times not on prophylaxing Track1B.Ritzius et al--8.20@2.30pm QC

Initial Z Score for 249 Patients Measure Phase Metrics Initial Z Score for 249 Patients Too busy….put on 2 slides Taske call ot and box medical and surgical Track1B.Ritzius et al--8.20@2.30pm QC

Pareto Charts for Medical – Surgical Patients

VTE Assessment / Prophylaxis Order Form Play with this slide Track1B.Ritzius et al--8.20@2.30pm QC

Pre - and Post - Pilot Performance Initial Z score for Surgical Patients 8.8% Defects Initial Z score for Medical Patients 57.1% Defects Change title Measure and Pilot/ or split up 11.9% Defects from pilot data for Medical Patients Track1B.Ritzius et al--8.20@2.30pm QC

Chi Square Test Results From Pilot A P-value of < .05 shows a statistically significant difference Chi Square Test: # Passed-Failed

patients identified at risk for VTE Project Performance Project Y Data Type Test Initial Performance Current Statistical Significance Not prophylaxing patients identified at risk for VTE Discrete Z- Calc & Chi - Square Z = 0 Z = 2.68 P- value < .05

Accomplishments Presentations throughout Virtua: Gage completed with 95% confidence Shared learning with Physicians from Deborah hospital Piloted electronic chart reviews Pilot program completed with three Physician groups Presentations throughout Virtua: P&T VTE Education with CEU’s Forms Committee Development of TRIP sheet Medical Exec for each division Virtua Vine Intranet Education Quality and Risk Committee Guess the Calf Contest Quality News letter NEC – MPNEC Surgical Council Pharmacy Directors Vendor Expo participation Unit Based Council Education All day poster presentations on each campus Individual presentation to physicians / physician groups Unit Secretary education Dr. Chelemer and Dr. Sutherland worked together with the VTE team to develop the final form for VTE prophylaxis, and presented the form to key committees and departments. Administration and Sponsors were very supportive that this was the direction needed to be taken, decision to not close post pilot and to roll out process at all devsions. Identified process owners at each location , extensive education and presentations accomplished Track1B.Ritzius et al--8.20@2.30pm QC

Mobilizing Commitment Changing Systems & Structures Change Acceleration Process : Leading Change Creating A Shared Need Shaping A Vision Mobilizing Commitment Current State Transition State Improved State Challenges identified at campus wide roll out. @ each campus separate medical staffs, Constant reinforcement of usage of the forms Physicians posed the biggest obstacle to success. Physician champions help to lead the change as well as governing bodies of healthcare Making Change Last Monitoring Progress Changing Systems & Structures Track1B.Ritzius et al--8.20@2.30pm QC

Quality X Acceptance = Effectiveness Formula for Change Q x A = E Quality X Acceptance = Effectiveness Talking point that focus needs to be placed on the acceptance part of the equation many quality efforts fail due to lack of attention to the cultural and people side of change -- the “A” Track1B.Ritzius et al--8.20@2.30pm QC

Performance after Project implementation to all campuses Virtua overall…….discuss opportunity of improvement with OA’s reporting the data to the physicians Track1B.Ritzius et al--8.20@2.30pm QC

Future VTE Measures VTE prophylaxis addressed in surgical patients with SCIP Joint Commission/NQF Project – currently testing measures NQF VTE Steering Committee will recommend specific measures Anticipate 2008 NQF will endorse measures No specific plans for implementation Discuss control plan involving the Quality department Track1B.Ritzius et al--8.20@2.30pm QC

Lessons Learned System wide focus Focus on broad range of VOC when dealing with multiple medical staffs “Over-communicate” More CAP with physicians: Q X A = SUCCESS CORE measures can often drive physician compliance Six Sigma is effective for clinical settings Development of EMR will improve compliance Discuss obstacles faced with 2 medical staffs and trying to change Physician practice Track1B.Ritzius et al--8.20@2.30pm QC

How likely is this project to be successful ? Cap – O – Gram C 4/17/07 How likely is this project to be successful ? 100% 90 88 95 C 8/16/06 96 90 80 93 95 88 95 88 92 95 90 75 80 80 90 75 80 80 70 75% 80 75 70 75 75 I 3/17/06 70 70 70 60 65 60 55 A 4/1/06 50% 50 50 45 45 45 M 3/1/05 Discuss why 2 Cap O Grams were completed to end the project 35 25% 25 D 1/1/05 Leading Change Creating a Shared Need Shaping a Vision Mobilizing Commitment Making Change Last Monitoring Progress Changing Systems & Structures Track1B.Ritzius et al--8.20@2.30pm QC

WHAT YOU DON’T KNOW COULD KILL YOU… LEARN WHAT YOU CAN DO TO PREVENT VTE TODAY. Contact Information: smindel@virtua.org – trodgers@virtua.org- jritzius@virtua.org Track1B.Ritzius et al--8.20@2.30pm QC