Qualitative Analysis
Qualitative analysis: diagram care delivery to identify failure modes
What the team learns from drawing and discussing a map of the current process can be frankly surprising. The team may identify wasted or duplicated efforts, lack of consensus on the current process, hidden complexities, and opportunities to streamline or simplify.
The figure below diagrams the steps in care delivery for preventing hospital-acquired VTE. As a starting point for discussion, the team could try to estimate how often each step occurs. For those steps that occur less than 100% of the time, have the team list those things that can and do go wrong in the current system. This simple qualitative analysis may reveal steps in the current process that are so obviously unreliable or faulty that they become the natural focus of interventions. Make an attempt at this point to prioritize these “failure modes.” Examples of actual failure modes on the next page may be helpful to review or discuss.
Actual Failure Modes (from UCSD and Emory):
- VTE risk assessment not routine or standard
- Bleeding risk assessment not routine or standard
- Most “appropriate” prophylaxis option for each level of risk not conveniently available for provider
- Differing opinions or lack of awareness of how at-risk some medical or surgical patients are
- Differing opinions on what is “appropriate” even among our experts
- Protocols: Ortho has > 4, Surgery has > 4, Medicine has 0, they don’t all agree.
- Noncompliance with mechanical prophylaxis (mechanical prophylaxis often on the floor, in the window sill, not in the room, or not delivered to room when patient admitted at night or over weekend)
- Unnecessary immobility: excessive sedation, unnecessary restraints, central lines, catheters, IV fluids, or O2 therapy
- VTE and bleeding risk can and do change, but no reassessment is routine or standard
- Platelet monitoring is haphazard when heparin ordered
- Over use of non-retrievable IVC filters
- Transfers out of ICUs may drop VTE prophylaxis
- Prophylaxis stopped at discharge even when risk continues in some patients after discharge.
- Peri – procedure and post-trauma: widely different impressions of when it is safe to start anticoagulation
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