Small Tests of Change VTE Travis Dollak Improvement Advisor WHA Courtesy Reminders: Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) Please do not take calls and place the phone on HOLD during the presentation.

Today’s Call 1.Past 30 Days 2.VTE Big Picture Strategy 3.PDCA Cycles A.Designing Tests B.Adapt, adopt, abandon 4.Tracking Innovation 5.Next 30 Days

ACTION ITEMS Develop Aim Statement Staff Safety Assessment Assess your interventions Test ONE intervention Submit Outcome and Process Measure Past 30 Days

Mid-month feedback Pace The pace is perfect A lot is being asked, but my team is keeping up Small Test of Change Improve discharge information Improve awareness of the need to ambulate

Poll Question #1 What progress have you made on analyzing the staff safety assessment /secondary drivers and choosing an initiative to test? a)We have not administered the staff safety assessment b)We administered the assessment and are still collecting the responses c)We have analyzed both the assessment and secondary drivers but have not chosen any interventions d)We have completed the analysis, chosen interventions and are testing the interventions

VTE Big Picture Strategy 1)Distill evidence into protocol 2)Integrate protocol with risk assessment into all admit/transfer orders 3)Ongoing monitoring of impact to tweak protocol 4)Devise method to detect those without prophylaxis in real time and intervene using multiple methods Source: Designing and Implementing Effective VTE Prevention Protocols, Greg Maynard M.D.

Poll Question #1 Results What progress have you made on analyzing the staff safety assessment /secondary drivers and choosing an initiative to test? a)We have not administered the staff safety assessment b)We administered the assessment and are still collecting the responses c)We have analyzed both the assessment and secondary drivers but have not chosen any interventions d)We have completed the analysis, chosen interventions and are testing the interventions

The Essential First Intervention 1)a standardized VTE risk assessment, linked to… 2)a menu of appropriate prophylaxis options, plus.. 3)a list of contraindications to pharmacologic VTE prophylaxis VTE Protocol Challenges: Make it easy to use (“automatic”) Mare sure it captures almost all patients Trade-off between guidance and ease of use/efficiency Source: Designing and Implementing Effective VTE Prevention Protocols, Greg Maynard M.D.

Mistakes in VTE Protocols/Prevention Orders Too Complicated No real guidance (Prompt ≠ Protocol) Too much ‘guidance’ collects dust Too many categories of risk Allowing mechanical prophylaxis too much Failure to pilot, revise, monitor Linkage between risk assessment and prophylaxis choices are separated Source: Designing and Implementing Effective VTE Prevention Protocols, Greg Maynard M.D.

VTE Prevention Order Too Complicated?

Other Simplified Protocols/Order Sets tnersforPatients/VenousThromboe mbolism/VTEReferences.aspx

Questions 13

Moving to PDSA Cycles avoiding the mistake of failing to pilot, monitor, and revise

A BIG Paradigm Shift The “old” 7 step process Need for Improvement Convene a Team Team determines the change needed Try it once or twice Write up the policy Hold the In service or Send Memo to Staff Hope Staff Change

The ‘Old Way’ The “old” 7 step process Data shows lots of DVT/PE cases Quality Lead and Manager Meet Need one of those new protocols ‘Test’ for a week Write up the policy, get it into the EMR Send Memo to Staff about new tool in EMR Hope Staff Change

A More Sustainable Process Sustainable Improvement Desire to Improve Convene a Team w/ Frontline Staff Staff determines change needed Identify process measure and design tests Conduct cycles of small tests (20- 40% of staff involved) Train on the new way, then “Hard Code” Monitor for Improvement & Accountability

The ‘New Way’ Sustainable Improvement Data shows potentially preventable DVT/PE cases Convene a Team w/ Frontline Staff Staff conducts staff safety assessment – need for specific discharge information Identify process measure and design tests Over 6 weeks 12 RNs test and adapt instructions Train on the new way, then “Hard Code” Monitor process measure to make sure instructions are used

Repeated Use of the PDSA Cycle Small Tests of Change 20 Changes That Result in Improvement Implementation of Change Hunches Theories Change Ideas AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change IHI – Adapted from “The Improvement Guide” by Lloyd Provost

Revise and Re-evaluate: Key Decision Remember the first interventions do not always work Adapt, adopt, abandon Adapt—make the changes needed to make it workable Adopt – keep it (document and report results) Abandon—let it go, if it didn’t work, don’t try to

Test of Change Design 22 TESTPREDICTIONRESULTS Decision 1. Want nurse X & physician Y on second shift unit B to use new protocol Faster assessment, more likely to understand/complete prophylaxis  Adapt 2. Improve ambulation on night shift with one RN Expect 80% compliance with night patient ambulation Nurse was able to meet prediction  Adopt 3. Want 2 physicians to use new protocol next Mon-Wed Expect 90% of patients to have completed assessment TBD  Adopt  Adapt  Abandon

23 TESTPREDICTIONRESULTS Decision 1. Want nurse X & physician Y on second shift unit B to use new protocol Faster assessment, more likely to understand/complete prophylaxis  Adapt 2. Improve ambulation on night shift with one RN Expect 80% compliance with night patient ambulation Nurse was able to meet prediction  Adopt 3. Want 2 physicians to use new protocol next Mon-Wed Expect 90% of patients to have completed assessment TBD  Adopt  Adapt  Abandon Tracking Test of Change is PDSA

Action Item# 1: Complete and Document 3 Small Tests of Change Complete 3 Small Tests of Change

Prioritize Your Interventions Low Impact High Impact Difficult to Implement Easy to Implement Flow sheet to follow patient Staff Safety Assessment idea Pharmacist round concurrently Target Area 1 Simplify screening tool Educate patients on risk of VTE

How to ‘speed up’ & try additional tests Getting others to try initiative, multiple tracks Improving Ambulation Education Process New Screening Tool/Protocol

Tips for Multiple Tests Scale down the scope of tests. Dimensions of the tests that can be scaled down include the number of patients, doctors, and others involved in the test ("Sample the next 3" instead of "Get a sample of 30"), Be sure your pilot is really a pilot. When possible, choose changes that do not require a long process of approval, especially during the early testing phase. Be prepared to end the test of a change. If the test shows that a change is not leading to improvement, the test should be stopped.

Tips for Multiple Tests Pick willing volunteers. Work with those who want to work with you. ("I know Dr. Jones will help us" instead of "How can we convince Dr. Smith to buy in?") Don’t reinvent the wheel. Pick easy changes to try. Use the change matrix. Avoid technical slowdowns. Don’t wait for the new computer to arrive; try recording test measurements and charting trends with paper and pencil instead.

TESTPREDICTIONRESULTS Decision 1. Want nurse X & physician Y on second shift unit B to use new protocol Faster assessment, more likely to understand/complete prophylaxis  Adapt 2. Improve ambulation on night shift with one RN Expect 80% compliance with night patient ambulation Nurse was able to meet prediction  Adopt 3. Want 2 physicians to use new protocol next Mon-Wed Expect 90% of patients to have completed assessment TBD  Adopt  Adapt  Abandon Action Item #2 – Sharing Between Facilities 29 Your Story

You are probably wondering… Won’t this take too much time?

Why go so slow? Engagement is Non-linear

Action Item #3: Determine your tipping Point # Staff involved in process x 20-30% = Tipping Point Example : 25 nurses who follow hourly rounding expectations x 20% = at least 5 nurses (tipping point)

Poll Question #2: Please choose the top two errors that you feel happen most frequently in your organization regarding improvement projects. Moved too fast to ‘Protocol and Procedure’ Not had the right people involved Forgotten to engage frontline staff in trying new changes – little buy in Not monitored your measures consistently over time Forgot to reinforce training on the new way of doing things Used the same core group of people to fix the problem Not address the root causes of performance deficiency

August Action Items ACTION ITEMS Complete 3 more cycles of your test OR Begin testing another intervention Be prepared to present your test of change log Determine your tipping point Submit Monthly Outcome and Process Measure

Poll Question #2: Results Please choose the top two errors that you feel happen most frequently in your organization regarding improvement projects. Moved too fast to ‘Protocol and Procedure’ Not had the right people involved Forgotten to engage frontline staff in trying new changes – little buy in Not monitored your measures consistently over time Forgot to reinforce training on the new way of doing things Used the same core group of people to fix the problem Not address the root causes of performance deficiency

Tools Available on WHA Quality Center July Webinar Tool Kit (staff safety assessment, prioritization matrix) August Test of Change Presentation Slide Deck Forums

Thank You! Questions? Mid Month Survey – Asking about pace, slides Please take survey following webinar Next webinar: September 12th 37