Chapter 3. Analyze Care Delivery

To create its intervention, the team will need to diagram care delivery, which should be viewed as a series of intermediate steps that lead to a clinical endpoint. Diagramming helps members understand interrelated steps and identify where failures occur. By analyzing care delivery the team can identify "rate-limiting" steps and recognize which steps should serve as metrics for preventing hospital-acquired VTE.

Diagram Care Delivery to Identify Failure Modes

What the team learns from drawing and discussing a map of the current process can be surprising. The team may identify wasted or duplicated efforts, lack of consensus on the current process, hidden complexities, and opportunities to streamline or simplify.

Figure 2 diagrams the steps in care delivery for preventing hospital-acquired VTE. As a starting point, the team should estimate how often each step occurs. For those steps that occur less than 100 percent of the time, the team should list those things that go wrong in the current system. This simple qualitative analysis may reveal steps in the current process that are so obviously unreliable that they become the natural focus of interventions. The team can make an attempt at this point to prioritize these failure modes. Case Study 3 lists examples of actual failure modes identified at the University of California, San Diego Medical Center and Emory University Hospitals that may be helpful during reviews or discussions.

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Analyze Care Delivery to Identify "Rate-Limiting Steps"

Ultimately patients and providers care most about final clinical outcomes, like whether or not a patient has developed a hospital-acquired deep vein thrombosis (DVT) or pulmonary embolism (PE). The opportunity to reduce the likelihood of hospital-acquired VTE begins the moment the patient is admitted and actually recurs every day. To help the team focus its time on the most high-yield interventions, it is extremely helpful to identify the most frequent sources of missed opportunities to prevent hospital-acquired VTE. To a perfectionist, these missed opportunities can be thought of as "rate-limiting steps." To an optimist, they may be thought of as "high leverage points" for improvement.

Empirical analysis of each step below is useful. The following brief audit exercise is useful and recommended. The team should randomly choose 20 to 30 charts on the pilot unit. Team members should then tally the prevalence of appropriate prophylaxis as judged by the team's new gold standard, the VTE protocol. Next, they should look at the charts of the patients who were not on appropriate prophylaxis. If mechanical prophylaxis alone has been ordered, they should look at the patient to determine if mechanical prophylaxis is being worn. This should take no more than 2 to 3 hours using the chart audit form at Appendix D. Once the chart audit is complete, the team can make a simple tally sheet of the type and number of failures or annotate the diagram at Figure 3.

With quantitative information, the improvement team can make rational choices when deciding which steps in care delivery to redesign and which steps to measure. For VTE prevention in the hospital at Figure 3, a key moment occurs when physicians write admission orders. At that moment at least two different types of failure modes appear to contribute significantly to a poor overall baseline prevalence of appropriate VTE prophylaxis.

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