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Virtua Health
Sharon Mindel, Pharm DTerry Rodgers, RN, MSNJeannie Ritzius, RN
TIME IS RUNNING OUTTIME IS RUNNING OUT : :
ST P THE CLOT!ST P THE CLOT!
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 + 2000 physicians 7,752 deliveries 8% Operating Margin - #1 in the state of NJ STAR Culture
Virtua HealthVirtua Health
Virtua receives the JCAHO Gold Seal for:Stroke Center at Memorial,Total Joint Program,and Spine Program
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
DVT + PE = VTEDVT + PE = VTE
Patient Group VTE Prevalence, % Medical Patients 50-70% General Surgery 15-40% Stroke 20-50% Hip/Knee Arthroplasty, Fracture 40-80% Major Trauma 50-80% Spinal Cord Injury 60-100% Critical Care Patients 10-33%
Risk of VTE in Hospitalized PatientsRisk of VTE in Hospitalized Patients
Project Title: Standard Practice for Venous Thromboembolism (VTE) Prophylaxis
Division (s): Marlton
Project Title: Standard Practice for Venous Thromboembolism (VTE) Prophylaxis
Division (s): Marlton
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
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
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
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
Increased Revenue
Decreased Expense
Decreased Delay in
Collection
Improved Quality
Patient Satisfaction
Increased Productivity
Target Project Benefits
Increased RevenueIncreased Revenue
Decreased Expense
Decreased Expense
Decreased Delay in
Collection
Decreased Delay in
Collection
Improved Quality
Improved Quality
Patient Satisfaction
Patient Satisfaction
Increased ProductivityIncreased
Productivity
Target Project Benefits
Increased Revenue
Decreased Expense
Decreased Delay in
Collection
Improved Quality
Patient Satisfaction
Increased Productivity
Target Project Benefits
Increased RevenueIncreased Revenue
Decreased Expense
Decreased Expense
Decreased Delay in
Collection
Decreased Delay in
Collection
Improved Quality
Improved Quality
Patient Satisfaction
Patient Satisfaction
Increased ProductivityIncreased
Productivity
Target Project Benefits
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 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
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
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
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
Data Sources:Medical Records and Net Access
249 Charts manually and electronically
Data Sources:Medical Records and Net Access
249 Charts manually and electronically
Measure PhaseMeasure Phase
95% Confidence Intervals for defects
Confidence --> 0.95Units --> 249
Opportunities --> 1TOP's --> 249
Defects --> 93
p(d) Percent ppm ZST Defects
Upper Limit on Failure Rate 0.4368 43.7% 436807 1.66 <= "worst case" => 108 95%
Nominal Value 0.3735 37.3% 373494 1.82 <= "best estimate" Confidence
Lower Limit on Failure Rate 0.3132 31.3% 313232 1.99 <= "best case" => 78 Interval
Initial Z Score for 249 Patients
Measure Phase MetricsMeasure Phase Metrics
84 63
57.1 42.9 57.1 100.0
0
50
100
150
0
20
40
60
80
100
Defect
CountPercentCum %
Perc
ent
Cou
nt
Medical Patients
93 991.2 8.8 91.2 100.0
0
50
100
0
20
40
60
80
100
Defect
CountPercentCum %
Perc
ent
Cou
nt
Surgical Patients
Pareto Charts for Medical – Surgical PatientsPareto Charts for Medical – Surgical Patients
Allergies:
Risk factors for Venous Thromboembolism (Points in Italics)
1 Acute infection 1 Nephrotic syndrome 2 COPD 5 Hip, pelvis or leg fracture
1 Age 40-60 1 Obesity 2 Immobility 5 Ischemic stroke
1 Central venous catheter 1 Pregnancy or post-partum 2 Major surgery 5 Major trauma
1 CHF or MI 1 Sepsis 2 Malignancy 5 Spinal cord injury
1 Estrogen use 1 Varicose veins 3 Age >75
1 Inflammatory bowel dx 2 Acute respiratory failure 3 Family history of VTE
1 Minor surgery 2 Age 61-74 3 History of VTE
Low Risk (score of 1 or less) Moderate Risk (score of 2) High Risk (score of 3 or 4) Very High Risk (score of 5+)
Early Ambulation Heparin every 8 hrs or 12 hrs Heparin every 8 hrs or Heparin every 8 hrs or
or Lovenox, or pneumatic Lovenox or pneumatic Lovenox AND pneumatic
compression device compression device compression device
* Active or recent GI or intracerebral hemorrhage * Recent intracranial, spinal or intraocular surgery
* Thrombocytopenia * Uncontrolled hypertension
* Coagulopathy * Recent thrombolytics
* Hypersensitivity to heparin or derivatives * Epidural Anesthesia/catheter within 12 hrs
* Patient on anticoagulant therapy for another indication * Lumbar puncture within 12 hrs
* Impending surgery
Orders for VTE Prophylaxis (see risk levels above for suggested ordering guidelines) Unfractionated Heparin 5000 units sq every 8 hours Unfractionated Heparin 5000 units sq every 12 hours
Enoxaparin (Lovenox) 40 mg sq daily Enoxaparin (Lovenox) 30 mg sq daily (if CrCl < 30mL/min)
Anticoagulation Not Indicated/Contraindicated re:
Pneumatic compression device Calf or Foot
Date: Time: Physician Signature:
Date: Time: RN Signature:
38455 (4/07) Physician Orders Pg.1 of 1
Adapted from the Seventh ACCP Conference on Antithrombotic Therapy. CHEST 2004;126(3):338S-400S
* Early ambulation is appropriate & encouraged for all patients *
MEDICAL ADMISSION VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS
Physician Printed Name:
MEDICAL ADMISSION - VENOUS THROMBOEMBOLISM (VTE ) PROPHYLAXIS ORDERS
Risk Levels
The following might be considered contraindications to anticoagulants:
Authorization is hereby given to dispense a chemically identical or therapeutically equivalent drug as authorized by the P&T Committee, unless the physician indicates otherwise.
VTE Assessment / Prophylaxis VTE Assessment / Prophylaxis Order FormOrder Form
95% Confidence Intervals for defects
Confidence --> 0.95Units --> 102
Opportunities --> 1TOP's --> 102
Defects --> 9
p(d) Percent ppm ZST Defects
Upper Limit on Failure Rate 0.1609 16.1% 160898 2.49 <= "worst case" => 16 95%
Nominal Value 0.08824 8.8% 88235 2.85 <= "best estimate" Confidence
Lower Limit on Failure Rate 0.04114 4.1% 41144 3.24 <= "best case" => 5 Interval
Initial Z score for Surgical Patients 8.8% Defects
95% Confidence Intervals for defects
Confidence --> 0.95Units --> 147
Opportunities --> 1TOP's --> 147
Defects --> 84
p(d) Percent ppm ZST Defects
Upper Limit on Failure Rate 0.65265 65.3% 652645 0.00 <= "worst case" => 95 95%
Nominal Value 0.57143 57.1% 571429 0.00 <= "best estimate" Confidence
Lower Limit on Failure Rate 0.48727 48.7% 487274 1.53 <= "best case" => 72 Interval
Initial Z score for Medical Patients 57.1% Defects
95% Confidence Intervals for defects
Confidence --> 0.95Units --> 134
Opportunities --> 1TOP's --> 134
Defects --> 16
p(d) Percent ppm ZST Defects
Upper Limit on Failure Rate 0.18665 18.7% 186652 2.39 <= "worst case" => 25 95%
Nominal Value 0.1194 11.9% 119403 2.68 <= "best estimate" Confidence
Lower Limit on Failure Rate 0.06981 7.0% 69813 2.98 <= "best case" => 10 Interval
11.9% Defects from pilot data for Medical Patients
Pre - and Post - Pilot PerformancePre - and Post - Pilot Performance
Expected counts are printed below observed counts PASSED FAILED Total 1 118 16 134 86.31 47.69 2 63 84 147 94.69 52.31 Total 181 100 281 Chi-Sq = 11.633 + 21.055 + 10.604 + 19.193 = 62.485 DF = 1, P-Value = 0.000
Chi Square Test: # Passed-Failed
Chi Square Test Results From PilotChi Square Test Results From Pilot
A P-value of
< .05 shows a
statistically
significant
difference
Project Y Data Type
Test Initial
Performance
Current
Performance
Statistical
Significance
Not prophylaxing
patients identified at risk
for VTE
Discrete Z- Calc &
Chi -
Square
Z = 0 Z = 2.68 P- value
< .05
Project PerformanceProject Performance
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.
• 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
Accomplishments
Change Acceleration Process :
Leading Change
Changing Systems & Structures
CurrentState
TransitionState
ImprovedState
Creating A Shared Need
Shaping A Vision
Mobilizing Commitment
Making Change Last
Monitoring Progress
Q Q xx A = E A = EQuality X Acceptance =
Effectiveness
many quality efforts faildue to lack of attention to the cultural and people side of change -- the “A”
Formula for Change
95% Confidence Intervals for defects
Confidence --> 0.95Units --> 527
Opportunities --> 1TOP's --> 527
Defects --> 326
p(d) Percent ppm ZST Defects
Upper Limit on Failure Rate 0.66025 66.0% 660249 0.00 <= "worst case" => 347 95%
Nominal Value 0.6186 61.9% 618596 0.00 <= "best estimate" Confidence
Lower Limit on Failure Rate 0.5756 57.6% 575605 0.00 <= "best case" => 304 Interval
Performance after Project implementation to all Performance after Project implementation to all campuses campuses
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
Lessons LearnedLessons 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
Leading Change
Creating a Shared Need
Shapinga Vision
MobilizingCommitment
ChangingSystems &Structures
MonitoringProgress
Making ChangeLast
Cap – O – GramCap – O – Gram
How likely is this project to be successful ?How likely is this project to be successful ?
60
70
65
45 50
35
90
70
60
45
25
70 75
45
55
7075
80
9590
50
758080
959695
I3/17/06
D1/1/05
M3/1/05
A4/1/06
90 88 80
75 7080 80
88908895
75
93 92
C8/16/06
C4/17/07
100%
50%
0
75%
25%
WHAT YOU DON’TKNOW
COULD KILLYOU…
LEARN WHATYOU
CAN DOTO
PREVENTVTE
TODAY.
Contact Information: [email protected] – [email protected] [email protected]