Chapter 1. Take Essential First Steps

Quality improvement (QI) teams must be set up for success and can only proceed with the support of the institution and an understanding of the local environment. Teams must anticipate milestones, set goals, and use a framework for improvement.

Ensure Support From the Institution

The time, energy, and expertise of a physician leader are necessary to drive improvement. But alone they will not be enough. Sponsorship and support from the medical center, specifically from key leaders, are absolutely essential. Basics, such as revisions to order sets, data collection resources, or tweaks of a health information system, may require special permission, fast-track approval processes, or dedicated personnel. While most obstacles will merely require patience or ingenuity, some may be insurmountable without the influence of executive leadership.

Real support should confer to the improvement team the authority and resources needed to design and manage change. The QI practitioner, such as a doctor, nurse, or risk manager, should pause long enough to get a commitment from the institution to back the effort. The single most effective way to attract this support is by aligning the goals of the QI effort with the strategic goals of the organization.

The QI practitioner must make hospital leadership aware of how an effective venous thromboembolism (VTE) prevention program aligns with its goals for medical care, performance reporting, customer service, and cost containment. A number of forces may fuel administrative interest in the project, including public reporting of hospital performance (e.g., The Joint Commission and National Quality Forum measures), cost savings from more efficient care, risk aversion, favorable payments for better care (e.g., pay for performance), nursing and medical staff retention (e.g., Magnet Recognition Program®), related projects (Surgical Care Improvement Project), and even quality for quality's sake. Further, the Centers for Medicare & Medicaid Services is currently considering the inclusion of hospital-acquired deep vein thrombosis (DVT) and pulmonary embolism (PE) in its list of events for which hospitals will no longer be reimbursed. Appendix A contains talking points and facts to assist in garnering support from hospital leadership.

Simple calculations that use back-of-the-envelope math can assist a QI practitioner in making gross estimates of the impact of VTE. Over 1 year, a 300-bed hospital that lacks a systematic approach to VTE prevention can expect roughly 150 cases of hospital-acquired VTE. Approximately 50 to 75 of those cases will be potentially preventable because of missed opportunities to provide appropriate prophylaxis. Approximately five of those patients will die from potentially preventable PE. Each hospital-acquired DVT represents an incremental inpatient cost of $10,000, while each PE represents approximately $20,000 in additional cost.

Another quick method of estimating the impact of a VTE prevention program uses coding information. The QI practitioner can run a query using all codes for DVT and PE. These codes, listed at Table 1, represent both hospital-acquired VTE and the cases admitted to the medical center with pre-existing DVT or PE. At least half will be hospital-acquired VTE, and if the VTE prophylaxis rate is 50 percent, half of those will be potentially preventable hospital-acquired VTE. Alternatively, a patient may be defined as having hospital-acquired VTE when the diagnosis code is a secondary, rather than a primary, diagnosis.

Table 1. Discharge Codes for Deep Vein Thrombosis and Pulmonary Embolism
(Updated March 2007)

Number	Code
453.40	DVT lower extremity not otherwise specified
453.41	DVT proximal lower extremity
453.42	DVT distal lower extremity
453.8	DVT not elsewhere classified
415.11	Iatrogenic PE
415.19	Other PE
Complementary codes of 997.2 and 999.2 qualify the above codes and may also be helpful

Both methods can generate a rough estimate of the impact of a VTE prevention program. A more robust and accurate approach is outlined in Chapter 4 and addresses performance tracking. A rough estimate, however, can paint a useful picture to demonstrate the need of a VTE prevention program to members of care teams and administrators.

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Survey Previous or Ongoing Efforts and Resources

In many ways, a multidisciplinary QI team is building, flying, and navigating an aircraft that is already airborne. It pays to know what resources or circumstances are already available. Experience, precedents, or skilled individuals can significantly assist an effort. Conversely, working at odds with an infrastructure or strategic goals can sabotage the project.

Many factors can affect the approach to, interventions of, and the performance tracking system for the improvement effort. The QI team should determine the answers to these questions:

• What is the existing QI infrastructure?
• What support or services are available for this project?
• Are there any ongoing QI initiatives to learn from or to leverage?
• Are there any initiatives that could influence support for a VTE prevention effort (e.g., pursuit of Magnet Recognition Program®, Ventilator Associated Pneumonia bundle, Surgical Care Improvement Project, or The Joint Commission or National Quality Forum proposed core measures)?
• What performance data on VTE prevention or VTE events already exist?
• Are there any major lessons from previous or ongoing interventions to prevent VTE?
• How successful were previous VTE risk assessments? Why? Were they integrated into order sets?
• Are there ongoing VTE educational or awareness activities for medical staff?
• Are hospital policies capable of enforcing provider performance (e.g., medication reconciliation, vaccinations, VTE prophylaxis, etc.)?
• How fragmented is care in the hospital? Are intensive care units (ICUs) open or closed?
• Are patients geographically cohorted by service or specialty?
• What are the existing practices for standardizing care transitions between settings (e.g., emergency room to floor, intensive care unit to floor, operating room to floor, direct admissions)?
• Can precedents be leveraged that have engaged patients in promoting medical staff accountability for any specific care goals?
• In what areas of the hospital are nurses engaged in promoting medical staff accountability for any specific care goals (e.g., daily goals worksheet or participation in multidisciplinary rounds)?
• In what precedent-setting ways do clinical pharmacists participate in care delivery (e.g., participation in multidisciplinary rounds, pharmacokinetics consults, pages to providers to adjust medication dosages for estimated glomerulo filtration rate, etc.)?
• Could the electronic health information or paging system relay clinical information to members of the care team (e.g., alerts by e-mail, text page, fax, or computerized physician order entry [CPOE])?
• Is there a precedent anywhere in the institution for feeding back individual or service line performance to providers?
• Does the medical center have an electronic medical record, CPOE, or digital radiology?

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Clarify Key Stakeholders, Reporting Hierarchy, and Approval Process

Every medical center has stakeholders who should be made aware of efforts. Often, these stakeholders are individuals, but they can also be committees, services, training programs, hospital initiatives, or departments. Typically, these groups will include the:

• Pharmacy and therapeutics committee.
• Nursing groups.
• Orthopedics, surgery, or trauma leaders.
• Patient safety committee.
• Operating room or peri-operative committees.
• Chief residents and residency program directors.
• Departmental committees.

Providing awareness of the effort to stakeholders and gaining their buy-in will be important to boost early adoption of interventions. They may also advance educational efforts and offer legal protection for information that is uncovered. Early use of the proper reporting structure and approval processes is wise.

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Assemble an Effective Team

QI efforts often originate from just a few thought leaders who see a gap between best practices and current practices. The VTE prevention team should include the members listed below.

Team Leader. The team leader should be a physician the medical staff respects and, ideally, have some topic expertise on VTE prophylaxis and anticoagulation. This physician is responsible for setting the agenda, the frequency and the collaborative tone of team meetings, and for communicating directly with administrative and medical staff committees.

A physician hospitalist leader, pulmonologist, hematologist, critical care physician, surgeon, or other physician leader is the best choice to hold this position of influence. Though the team leader does not personally take minutes, the team leader should edit and "own" the minutes for presentation to senior leadership.

The team leader needs commitment and contributions from other team members to move the initiative forward. The team leader and the team may need to recruit local champions based on service or hospital geography. For example, a pulmonary or critical care physician may lead efforts on VTE prophylaxis in the ICUs, but a hospitalist may lead efforts on the floors or wards. Alternatively, a hospitalist or other individual may lead the entire effort. Whatever the format, a coordinated effort is required across the entire spectrum of care.

Team QI Facilitator. The QI facilitator, who may or may not be a physician, should be someone with QI experience. The QI facilitator plays the pivotal role of ensuring the team functions constructively and the project stays on track. This role requires project management skills and, at times, may call for the ability to balance team dynamics or introduce appropriate QI tools. The QI facilitator need not have mastery of QI tools at the onset of the project but should have a readiness to acquire new tools and a talent for moving projects forward. Mastery of the VTE literature is not important for this position. For smaller-scale projects, the QI facilitator can be the same person as the team leader. For more ambitious projects or for projects involving buy-in from disparate physician and nursing groups, having a separate facilitator is strongly recommended.

Process Owners. Frontline personnel involved in the process of providing VTE prophylaxis in the hospital are essential for an effective team wishing to optimize VTE prevention. Process owners should come from each service (pharmacy, nursing, etc.) and geography (medical, surgical, ICU, etc.).

Information Technology and Health Information System Experts. From performance tracking to actual QI interventions, the contributions of information technology or health information system experts is pivotal. Enlist those who can report ICD-9 code frequencies at discharge, perform data entry, set up reports from the electronic clinical data warehouse and radiology, and serve as liaisons to the medical records office.

Team Members. While meetings with the whole team are invaluable, they can occasionally become impractical or impossible to schedule. Team huddles, where a fragment of the team meets briefly to advance action items, can be very effective for overall progress. How team members interact with one another is also important. The key dynamic for an effective team is the removal of authority gradients. Because the perspective of every team member is potentially critical, every perspective must be heard. Each team member must be comfortable expressing his or her viewpoint. Try to pick people who have reputations as collaborators. It is up to the leader and facilitator to enforce constructive team dynamics.

Listing the names and contact information for the VTE prevention team members and keeping the list updated, especially electronically or online, is very useful.

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Set General Goals and a Timeline

Setting a goal is a great way to help the team stay focused and communicate with stakeholders. For clarity of purpose and to overcome initial inertia in the early stages, the team needs only to agree on general goals (e.g., reduce cases of hospital-acquired VTE). The general goal also should be a "stretch," one that is aggressive enough to mandate a change in design from the current process to achieve it (e.g., eliminate preventable cases of hospital-acquired VTE).

In addition to setting a stretch goal, at this early stage it helps also to be clear about the initial and eventual scope of the effort (e.g., will the focus be on medical patients, surgical patients, or both?). Initially it is reasonable and even advisable to "take small bites" by piloting interventions on a small scale (e.g., eliminate preventable cases of hospital-acquired VTE from a specific medical floor).

Try to be as inclusive as possible about the eventual scope. Serial testing and learning on a small scale can make even very large projects more manageable. Improvement strategies can be spread to other areas (e.g., eliminate preventable cases of hospital-acquired VTE from all medical and surgical floors and all ICUs).

Lastly, the team needs a deadline to which it will hold itself accountable. The timeline should be ambitious but realistic. For piloting a single improvement intervention on a single medical floor, a timeline of 12 weeks is reasonable. For spreading a series of improvement changes across an entire system, 12 to 18 months may be more appropriate.

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Use a Structured Framework for Improvement to Plan and Guide Progress

For team members (and as a communication aide for stakeholders), there is great value in knowing how each of the team's activities contributes to the overall progress of the improvement effort. A coherent framework is as important to quality improvement as an understanding of aeronautics is for building aircraft.

The team will advance the quality improvement project along several fronts simultaneously. A logical flow for a QI project is summarized below.

1. Lay out the evidence and identify best practices. Determine what needs to be done for whom and then draft a VTE protocol to standardize it.
2. Analyze care delivery. Highlight the steps in the clinical workflow where interventions will have the highest yield.
3. Track performance with metrics. Set up regular data collection and charting that is reliable, inexpensive, and directly relevant to the aim.
4. Integrate the VTE protocol into the clinical workflow and layer other QI strategies that use high-reliability mechanisms.
5. Perform cycles of Plan-Do-Study-Act to perfect 3 and 4, above.

Figure 1 presents the five steps and depicts inter-relationships.

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