1. S YSTEM R EDESIGN OF THE D YSPHAGIA S CREENING T OOL AT R ICHARD L. R OUDEBUSH VA M EDICAL C ENTER Stroke QUERI Dawn Bravata, MD Virginia S. Daggett, MSN, RN Teresa Damush, PhD Laura Plue, MS Scott Russell, BS George Allen, MS Neale Chumbler, PhD Heather Woodward-Hagg, MS Linda Williams, MD Frontline Clinical Staff Celine Alba-Patina, RN Tamra Arnold, Pharm-D David Bickel, RN, CAC Anna Bober, RN Randi Bruns, RN Rebecca Chapman, SLP Vonda Coley-Mathews, RN Jan Korte, RN Diane Longerbone, Dietician Katherine Sisk, RN

2. O BJECTIVE Describe use of Lean methodology to redesign dysphagia screen by a frontline, multidisciplinary staff in response to OIG directive.

3. S IX S IGMA L EAN M ETHODOLOGY : D EMING P HILOSOPHY Six Sigma – 99.99966% performance level Creating Intellectual Capital Five Sigma- 99.977% performance level Competitive Breakthrough Four Sigma- 99.370% performance Continuous Improvement Three Sigma-93.32% performance level Compliance Two Sigma- 69.2% performance level Capability One Sigma- 31% performance Control < One Sigma < 31% performance level Containment Six Sigma = 3.4 per million units Five Sigma = 230 per million units Four Sigma = 6,210 per million units Three Sigma = 66,800 per million units Two Sigma = 308,000 per million units One Sigma = 690,000 per million units Most VA Performance Measures

4. National Agencies or Organizational Standards & Guidelines  OIG Dysphagia Directive: “…Nursing assessment…must be conducted on all incoming patient within 24 hours of admission at all VA facilities…”  JCAHO Requirements: “A screen for dysphagia should be performed on all ischemic/hemorrhagic stroke patients before being given food, fluids, or medication by mouth.”  American Speech-Language-Hearing Association (ASHA) literature

5. Current State at Roudebush VAMC Dysphagia treatment/management processes are not effective, resulting in:  Dysphagia screening tool is inadequate (sensitive but not specific).  Too many people place on NPO upon admission.  Additional burden on nursing and speech/language pathology staff.  Inadequate outpatient follow-up for dysphagia.  Delay in administration of oral medications.  Confusion with respect to diet requirements upon discharge and positive screens.

6. Voice of the Customer RNs:  Screen is not user friendly  RNs feel frustrated when consult is cancelled by physician; “Waste of time”  Screen Questions do not pertain to the patient Physicians:  Physicians not aware of the screen; rely on H&P Dieticians:  Staff not aware of the assessment; patients not on NPO; trays are wasted

7. Patient Enters Hospital Patient Assigned to Ward Call Resident Orders Initiated Yes No ER Delays Room Cleaning Order Delays Med Pass Delays Wait for CT Family Providing Food 5S: No Admit RN Until 10:30a Patient Has Orders? Diet Order? Admit RN? Prior to 2:30pm? Admit RN Conducts Assessment RN Assigned Conducts Assessment PROCESS MAPPING CURRENT STATE PRE-ASSESSMENT

8. Dysphagia Assessment Conducted RNs not Screening Correctly Order Consult? Lack of Education Other Patient Needs Clinical Status Change Unconscious Assessment Using Previous Assessment Admit RN Capacity RN Distractions No Sip Test Questions Not Appropriate MD Cancels Order H&P Impact Assessment RN Not Checking Consult Box No RN Policy Stroke History Clinical Judgment RN Choice Per Policy No Consult To Surgery Positive Screen? Dr. Approves Consult? NPO Order Signed? RN Makes NPO RN Contacts Dr for Order No Policy To Call Lack of Communication Patient Not Labeled NPO Current State Process Map Assessment  Order Consult

9. T IME TO A DMISSION A SSESSMENT Range = 1 hour to 12 hours

10. A DMISSION AND D ISCHARGE V OLUME BY H OUR OF D AY

11. SLP C ONSULTS BY M ONTH Dysphagia Screen Starts - 98% of Admissions Screened - 8.2% of Admissions Screened Positive

12. T IME FROM C ONSULT TO SLP A SSESSMENT 28% (4/14) of observed patients were found to not have dysphagia by SLP

13. Current State Summary  ~50% of all observed patients (N=8) arrived on unit without orders  Admission Assessment occurs an average of 3 hours following Assessment (range 1-12 hours)  2030/2071 (98.0%) of all veterans admitted to the facility received screening  166/2030 (8.2%) had a positive screening  46% of observed patients (N=14) were put on NPO following a positive screen  28% (N=14) of observed patients that failed screen were found to not have dysphagia

14. P LAN, D O, S TUDY, A CT (PDSA C YCLES ) StageDescriptionStepsComments Plan Plan the test or observation, including a plan for collecting data. 1)State the objective of the test. 2)Make predictions about what will happen and why. 3)Develop a plan to baseline the current process and test the change. (Who? What? When? Where? What data need to be collected?) Redesign the dysphagia screening tool. Do Try out the test on a small scale. 1)Carry out the test. 2)Document problems and unexpected observations. 3)Begin analysis of the data. Perform usability testing on the redesigned tool. Study Analyze the data and study the results. 1)Complete the analysis of the data. 2)Compare the data to your predictions. 3)Summarize and reflect on what was learned.  Adapt, Adopt, Abandon? Determine metrics of measurement to analyze the performance of the redesigned dysphagia screen and measure sustainability. Act Refine the change, based on what was learned from the test. 1)Determine what modifications should be made. 2)Prepare a plan for the next test. Refine the screening tool based on data or analyze the performance of the original screen in general veteran population, not limiting to acute stroke patients.

17. Usability Testing  Patient Actors were used to provide consistent responses to each of the Users.  Eight Users (RNs) interviewed each of the eight Patient Actors once, using the old design four times.  Ordering of patients and test designs were balanced to offset learning factors.

18. U SABILITY T ESTING L AYOUT Station 2 Station 1 Queue Area with Snacks Observer User Patient Actor

19. Usability Study Feedback  New design received consistently higher scores in user satisfaction  New design showed fairly consistent improvement in task time (~40 sec mean)  Old design performed similar screening, but did not perform similar consult ordering  New design showed an increase in unnecessary consults

20. U SABILITY T ESTING

21. U SABILITY S TUDY S CREENINGS - 5 false positive screens due to patients with difficulty ‘swallowing large pills’ -2 consults missed due to not checking the consult box - False Negatives screens due to one left side paralysis patient

23. S OLUTION R ANKING

24. D EVELOP C ONTROL P LAN Process Monitors:  Time from Admission to Dysphagia Screen  % of Patients placed on NPO following positive screen  Sensitivity of new screening tool - Positive Rate - False Positive Rate - False Negative Rate

25. T HOUGHTS FOR D ISCUSSION  For hospitalized veterans with acute stroke, the re-designed dysphagia screen did not improve performance.  Change of patient status during hospitalization.  Context of the screen: -what discipline in terms of patient safety, work flow -when/where in point of care  Consistency in policies: IG directive and JCAHO.  Is nursing performing a dysphagia screen or an aspiration risk assessment?