virtua health sharon mindel, pharm d terry rodgers, rn, msn jeannie ritzius, rn

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



Increased ProductivityIncreased

Productivity


Increased Revenue

Decreased Expense

Decreased Delay in

Collection

Improved Quality


Increased Productivity


Increased RevenueIncreased Revenue

Decreased Expense

Decreased Expense

Decreased Delay in

Collection

Decreased Delay in

Collection

Improved Quality

Improved Quality



Increased ProductivityIncreased

Productivity


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




Defects --> 9





Initial Z score for Surgical Patients 8.8% Defects




Defects --> 84





Initial Z score for Medical Patients 57.1% Defects




Defects --> 16





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




Defects --> 326





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]

virtua health sharon mindel, pharm d terry rodgers, rn, msn jeannie ritzius, rn

Documents

vte slide

risk of vte

prophylaxis of patients

medical surgical patients

prophylaxing patients

medical patients pre

vte usl

vte target