1. 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 QC

2. ST P THE CLOT! TIME IS RUNNING OUT :
Track1B.Ritzius et QC

3. 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 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

4. 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 QC

5. Risk of VTE in Hospitalized Patients
Patient Group VTE Prevalence, %
Medical Patients %
General Surgery %
Stroke %
Hip/Knee Arthroplasty, Fracture %
Major Trauma %
Spinal Cord Injury %
Critical Care Patients %

6. 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 QC

7. 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 QC

8. 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 QC

9. Pareto Charts for Medical – Surgical Patients

10. VTE Assessment / Prophylaxis
Order Form
Play with this slide
Track1B.Ritzius et QC

11. 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 QC

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

13. 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

14. 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 QC

15. 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 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 QC

16. 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 QC

17. 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 QC

18. 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 QC

19. 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 QC

20. 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 QC

21. WHAT YOU DON’T KNOW COULD KILL YOU… LEARN WHAT YOU CAN DO TO PREVENT
VTE
TODAY.
Contact Information: –
Track1B.Ritzius et QC