1. Dorothy Jenrette, PharmD, BCPS Ralph H. Johnson VA Medical Center
Improving Deep Vein Thrombosis (DVT) Pharmacological Prophylaxis in Hospitalized Patients A Healthcare Failure Mode and Effects Analysis (HFMEA)
Dorothy Jenrette, PharmD, BCPS
Ralph H. Johnson VA Medical Center

2. APPROACHING & FRAMING PROCESS IMPROVEMENT
PDSA
TAMMCS
SIX SIGMA
LEAN
VALUE ANALYSIS TEAMS
QUALITY CIRCLES
TQM
JURAN’S TRILOGY
All quality intervention methodologies are interrelated…….

3. APPROACH / METHODOLOGY
Value of “branding”……
INCREASE EFFICIENCY
LEAN
SIX SIGMA
IMPROVE QUALITY
….standardization & continuity.

4. FRAMEWORK
VA-TAMMCS
PDSA

5. TEAM Dorothy Jenrette, PharmD Christina Goodear, PharmD
William Shelley, MD, Inpatient Medical Service
Jason Trigiani, PA, Surgical Service
Kim Davis, RN, ICU Nurse Manager
Kathleen Fowler, RN, Inpatient Med/Surgery Clinical Nurse Lead
Diane Styk, NP, ICU
Lynn Tinkham, VASQIP
Zola Driggers, NP, Anesthesiology Pre-op
Amy Manigo, Surgical Service Coordinator
Lorie Reed, RN, Primary Care
Ryan Buckley, MD, Chief Resident for Quality and Safety
Patrick Harrell, PSM and Mark Lockett, MD (Ex-Officio)
Gordana Milosevic, PharmD, Facilitator / Green Belt Student
Deborah Cutts, Green Belt Coach

6. Reason for action Problem Statement:
Plan +
Reason for action
Problem Statement:
Acute Care, IPEC* data FY14 - 2QFY15 - consistently below the national mean for high risk diagnosis/procedures receiving DVT prophylaxis.
ICU Care, IPEC data FY14 - 4QFY15 - four of eight performance quarters fell below the national mean / experienced adverse patient outcomes related to this process.
In Scope: Surgery patients receiving DVT prophylaxis, medicine patients receiving DVT prophylaxis
Out of Scope: Patients receiving DVT treatment and/or mechanical DVT prophylaxis
*IPEC is a national program focused on providing process and outcome metrics that identify opportunities for improving patient outcomes across care environments.

7. Plan +
Current State
56.4%
74.9%
% high-risk diagnoses or procedures administered pharmacologic VTE prophylaxis within 24 hours after diagnosis or procedure end time.
Surgical end time not available – 26 hours from the start time of the procedure used to reflect approximate surgical time.

8. 14 High Level Process Steps
Plan +
Current State
Current State Process through a Healthcare Failure Mode Hazard Analysis
14 High Level Process Steps
44 Sub Process Steps
124 Failure Modes

9. Plan +
Target State
AIM
Develop a standardized approach to DVT risk assessment and proactive intervention.
Improve the percent of acute care patients receiving timely and appropriate VTE Prophylaxis from a baseline 60% to consistent performance of 95% by September 2016.
Improve the percent of ICU patients receiving appropriate and timely VTE Prophylaxis from a baseline 60% to a consistent performance of 85%, with a stretch goal of 95%, by September 2016.

10. Current State Performance Target State Performance
Plan+
Target State .
Metric
Current State Performance
Target State Performance
Percent of acute patients receiving appropriate and timely VTE Prophylaxis
 60%
 Sustained 95%
Percent of ICU patients
receiving appropriate and timely
VTE Prophylaxis
 Sustained 85%

11. Plan +
Gap Analysis
Problem Statement
Direct Cause
Root Cause
Inconsistent assessment of risk
Ability to bypass the templated risk assessment
Electronic record has various templates
No force function to document contraindication or opt out
Templated risk assessment is not user friendly and is not a hard stop step in completing clinical documentation
Preop / postop anticoagulation not always ordered / administered appropriately or timely
Incorrect / unclear medication order start times
Process allows a provider to skip the steps necessary to complete the process
Documentation order does not flow naturally
The templated risk assessment is not user friendly and is not a hard stop step in completing clinical documentation
Lack of communication among the clinical team
No clear delineation of who has ownership
Skewed historical / cultural perception of the role of the nurse – not always empowered to voice patient care concerns to other clinical team members
Lack of clinical pharmacist involvement
Absence of a multidisciplinary clinical TEAM , i.e., multidisciplinary patient rounds, hand off, etc.

12. Solutions / Countermeasures
Do+
Solutions / Countermeasures
If we……
Then we expect……
Trigger risk assessment early in the clinical flow and develop standardized consistent versions across all notes
Providers will be more likely to complete the risk assessment process
Make the risk assessment a hard stop for clinical documentation and integrate the medication order into the completed risk assessment flow
Providers will be more likely to complete the risk assessment and place the VTE order clearly and timely
Include a dedicated section in the risk assessment to document contraindications / reasons why DVT prophylaxis may not be appropriate for the patient
Other members of the clinical team will have a clear picture of the provider’s intent
Take an opportunity to include relevant nurses and pharmacists in existing standardized approaches for treatment planning and review
A more multidisciplinary approach to delivering care provides an opportunity for key clinical team members to raise concerns and provide relevant/ helpful information

13. Test of Change (Cycle of Refinement)
Do+
Rapid Experiments
Test of Change (Cycle of Refinement)
Target
Performance Achieved
Cycle #1
Cycle #2
Cycle #3
H&P DVT risk assessment revised to add consistency and reflect a simplified flow (mandatory).
100%
93%
 100%
H&P risk assessment revised to prompt for documented contraindications when appropriate (mandatory).
 84%
Note templates revised to prompt for documentation of nursing and physician
daily assessment (mandatory).
66%
 88%
This list should be made up of new or revised steps in the process you implement and study to determine effectiveness versus a list of team deliverables which can be tracked off line.
Several small cycles of refinement…… measured frequently

14. Implementation / Completion Plans
Do+
Implementation / Completion Plans
What
Who
By When
HARD STOP forcing function - risk assessment in all History & Physical Templates
CAC/Team Leads
July 2016
Standardize pre-operative administration of anticoagulation to the “holding area” / insert line item in holding nurse checklist
 Holding room nurse/
Team Leads
July 2016 
Insert DVT risk assessment with selectable medication “quick orders” into all admission and post-operative order sets
Revise DVT prophylaxis orders to require the prescriber to
note desired start date and time
August 2016
Daily progress note HARD STOP forcing function – prophylaxis indicated / no-why not
CAC/Team Leads 
Nursing Daily Assessment HARD STOP forcing function prophylaxis ordered yes/no
Daily surveillance of DVT prophylaxis orders in newly admitted patients
Pharmacy
December 2016

15. H&P DVT Risk Assessment

16. Admission Orders with Quick Orders

17. Pharmacologic Prophylaxis Orders
Heparin
Enoxaparin

18. Target State Performance Target State Performance
Measure / Change
Confirmed State
Acute Care
Target State Performance
 Sustained 95%
ICU
Target State Performance
 Sustained 85%

19. Actions planned to improve
ACT / SPREAD Potential
Insights
Went really well……..
Who do we thank
Key stakeholders/services participating – involve each process owner/participant
Surgery, QM, Nursing CNL, Inpatient pharmacy, employees involved in previous tests of change
(historical perspective helped)
Use of standardized work / analysis process, i.e. HFEMA, Lean Six Sigma AFTER team members were oriented to these tools
 Systems Redesign
Didn't go so well……
Actions planned to improve
Doing the actual work while also learning the tools, i.e., HFMEA, Lean, etc.
Step up formal training before the actual teams kick off.
Consider appointing team members who have previously gone through the same process.
Variety of key process owners chosen and ultimately at the table doing the work
Thoughtful approach to team member selection.
Strong service level leadership to ensure process owners freed up to be at the table and that expectations for fully participating are clearly communicated.

20. Dorothy Jenrette, PharmD, BCPS
Thank you!
Dorothy Jenrette, PharmD, BCPS
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Questions?