1. Getting Started on Venous Thromboembolism (VTE) Travis Dollak Improvement Advisor WHA 1

2. Today’s Call 1)Our Timeline and Process 2)Review Questions from Kick-Off 3)Measures (Q&A) 4)Next 30 Days A.View Science of Safety Video B.Organizing the Team 2

3. VTE Facts Pulmonary Embolus resulting from DVT is the most common cause of preventable hospital death The risk for developing VTE varies between 10-85% (depending on reason for admission) The rate of fatal pulmonary embolus more than doubles between the ages of 50 and 80 If Wisconsin prevents 125 DVTs in the next two years we will save our state $1.9 million (~$15K/instance) http://www.hret-hen.org/images/downloads/508changepacks/vte_change%20package_508.pdf

4. Initiative Timeline Overview 9 Month Collaborative 1-Hr Webinar Each Month – 2 nd Wednesday of Each Month 12:00-1:00 PM 4

5. 5 Reduce VTE by 50% Effective Risk Stratification Simplified Screening tool - low, medium, high risk Screen on admission & transfer Standardized Care Process Develop, adopt, apply best practices Develop standard order sets Allow "opt-out" methodology Develop ambulation protocols Decision Support Flow sheets that follow patient Pharmacist round concurrently Pharmacists assist with contraindications DRIVER DIAGRAM

6. 6 Reduce VTE by 50% Prevention of Failure Independent double check on prophylaxis orders Pharmacists review all "opt- outs" Identification and Mitigation of Failure Educate patients on risk of VTE Utilize frontline clinicians as "first responders" Smart Use of Tech Link order set to risk stratification tool Link order set to recent lab values Use alerts for weight-based dosing of heparin DRIVER DIAGRAM continued

7. Poll Question #1: What have you tried? Which of the following describes your facility best in terms of progress on this initiative? a)This is the first time we have worked on it b)We have worked on it in the past but feel we have regressed c)We have really nailed it and are putting the finishing touches on the program d)We have all but given up on finding ways to improve 7

8. Initiative Learning Process Webinars Review progress of last 30 days New content Discussion and sharing Plan for the next 30 days Discussion Group Questions Peer-to-Peer Sharing Quality Center Data submissions References and Toolkits Reports (coming soon) Learning Opportunities Webinars Discussion Group WHA Quality Center Site Visits 8

9. Theory of Constraints Reasons Improvement Projects May Have ‘Failed’ in the Past: Moved too fast to ‘Protocol and Procedure’ Did not have the right people involved – engaging frontline staff Used the same core group of people to fix the problem Measures were not monitored consistently over time Did not reinforce training on the new way of doing things Participants in the initiative do not address the root causes of performance deficiency 9

10. Poll Question #1: Results Which of the following describes your facility best in terms of progress on this initiative? a)This is the first time we have worked on it b)We have worked on it in the past but feel we have regressed c)We have really nailed it and are putting the finishing touches on the program d)We have all but given up on finding ways to improve 10

11. How we will overcome the Constraints Slow down the improvement train Continuous measurement throughout initiative (and beyond) Get the right people involved Get new people involved Small tests of change with many front-line staff Opportunities to revisit training Focus on project sustainability 11

12. Findings from Kick-Off Meeting Follow-up from Post-Its on Quality Center Discussion Group Concerns Questions Something to Share 12 http://www.whaqualitycenter.org/PartnersforPatients/VenousThromboembolism/VTEDiscussionGroup.aspx

13. Importance of Measurement Why process measures?  The purpose of measurement in QI work is for learning not judgment!  Measures should be used to guide improvement and test changes.  Demonstrate change from a baseline, or initial measurement, and assess the degree of change after an intervention. I think we improved… but I’m not sure by how much? 13

14. Outcome Measure: Focus on the customer or patient. What is the end result? VTE Outcome Measure: Incidence of hospital-acquired VTE (# of VTE per 100 admissions) VTE Outcome Measure 14

15. VTE Process Measures 15 Process Measures: Focus on the workings of the system. Are the parts/steps in the system performing as planned? VTE Process Measures: Completion of a risk assessment on admission using risk assessment tool Or Prevalence of appropriate prophylaxis (educational, pharmacological, mechanical)

16. Action Item #1 – Data Submission Baseline outcome data due June 30 th Submit via WHA Quality Center Portal o 2011 Data Aggregate (if available) and/or o 2012 Data Monthly (if available) Analyze baseline data 16 http://www.whaqualitycenter.org/PartnersforPatients/VenousThromboembolism/VTEDataSubmission.aspx

17. Plan for the Next 30 Days 1.Science of Safety 2.Organizing the Team 17

18. Poll Question #2: Where are you at? Which of the following best describes your progress on this initiative? a)Team formed – AIM statement – Held first team meeting -- Analyzing interventions b)Team formed – AIM Statement -- Held first team meeting c)Team formed -- AIM Statement d)Team formed e)Just starting 18

19. 19 The Swiss Cheese Model – by James Reason Science of Safety – How Errors Happen

20. How Can These Errors Happen? People are fallible Medicine is still treated as an art, not a science Systems do not catch mistakes before they reach the patient 20

21. Why do mistakes happen? Variability based on patient type Complexity Inability to connect risk assessment with care plan Human error Tight time constraints Inadequate tools (protocols, policies, supplies) Fatigue Inattention/distraction Unfamiliar situations/new problem Communication errors Using past solutions 21 Process FactorsPeople Factors

22. Seven Concepts of Patient Safety #CONCEPTVTE SPECIFIC 1Use-Centered Design (staff providing care) Make things visible Simplified screening tool 2Avoid Reliance on Memory Vigilance Provide checklists, flags or alarms as reminders Use a flow sheet that follows the patient through the transitions of care 3Involve Patients in Their Care Teach back Educate patients and families on risk of bleeding or early signs of VTE 22

23. Seven Concepts of Patient Safety #CONCEPTHAC SPECIFIC 4Anticipate the UnexpectedHave pharmacists perform independent double checks on prophylaxis orders 5Build in Redundancy Assume errors will occur and build a system to accommodate Have pharmacists perform concurrent review of all “opt-outs” 6Hardcode Your System (process, training, culture) Utilize frontline clinicians as “first responders” for over/under coagulation 7Improve Access to Timely Data Data walls Make results easily available and visible to all. Post run charts at stations. 23

24. Science of Safety Recipe Educate on the Science of Safety Identify Defects (Staff safety assessment) Learn from Defects Implement Teamwork, Communication Tools, A standardized process 24

25. Action Item # 2 – View Patient Safety Video Create a roster of who on your team/unit needs to view the Science of Safety video. http://www.youtube.com/watch?v=GOJJH Hm7lnM&feature=results_main&playnext =1&list=PL048D28C888FE3871 25

26. Organizing your Team Considerations – Who will you involve? – How will you communication? Within your team? (notify of meetings) To others outside of thee team? – How will you use the webinars? (use as weekly meeting?) – Identify team structure (key roles, expertise, leaders) – How will you keep everyone engaged? 26

27. Poll Question #2: Results Which of the following best describes your progress on this initiative? a)Team formed – AIM statement – Held first team meeting -- Analyzing interventions b)Team formed – AIM Statement -- Held first team meeting c)Team formed -- AIM Statement d)Team formed e)Just starting 27

28. Action Item #3 - Organizing your Team Optional Tools to Use Agenda Team Charter 28

29. Guide to Quality Center http://www.whaqualitycenter.org/ http://www.whaqualitycenter.org/ Click Here 29

30. The Next 30 Days Tools Available On WHA Quality Center: Science of Safety Video Link Meeting Agenda (pre-populated) Team Charter VTE References and Toolkits ACTION ITEMS Submit Baseline Data View Science of Safety Video Hold an initiative team meeting Review Resources in Quality Center 30

31. Questions? 31 Reminders: Please complete the 3 question survey when you close the webinar window. Mid-month reminder email Next Month begin the Model for Improvement