Society of Hospital Medicine SHM
HomeLogoutCareer CenterSHM CommunityQI Resource Rooms 
 
sitemap contact questions
Advanced Search
About SHM
Membership
Education
Quality Improvement
 
QI Current Initiatives and Training Opportunities
 
QI Primer
 
QI Clinical Tools
 
QI Resource Rooms
            
Practice Resources
Advocacy
Events
Publications
News and Media
Join SHM
SHM Store


Exchange Information Implementation Guide Professional Development Resource Room Project Team Main Resource Room Home Venous Thromboembolism Resource Room

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. You may identify wasted or duplicated efforts, lack of consensus on the current process, hidden complexities, and opportunities to streamline or simplify.

Below you see a generic diagram of the steps in care delivery for preventing hospital-acquired VTE. As a starting point for discussion, have your team estimate how often each step (each box) 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 your current system. With nothing more than this qualitative analysis you may find some steps in your current process are so obviously unreliable or faulty that they become the natural focus of your interventions. Make an attempt at this point to prioritize these “failure modes.” If you get stuck, examples of actual failure modes on the next page may be helpful to review or discuss.

Figure 2-1

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

 

 

 

Venous Thromboembolism Resource Room Project Team
This resource room is sponsored in part by an unrestricted educational grant from Sanofi Aventis

Disclaimer
The Venous Thromboembolism (VTE) Resource Room is an online resource for visitors to the Society of Hospital Medicine’s website. All content and links have been reviewed by the VTE Resource Room Project Team, however the Society of Hospital Medicine does not exercise any editorial control over content associated with the external links that have been made available via this website.

The contributions of Dr. Maynard and his UCSD collaborators in the development of the SHM VTE Prevention Resource Room and the VTE Prevention Implementation Guide were supported by grant number 1U18HS015826-01 from the Agency for Healthcare Research and Quality (AHRQ). The contents of this product are solely the responsibility of Dr. Maynard and the SHM VTE Resource Room team, and do not necessarily represent the official view of or imply endorsement by AHRQ or the U.S. Department of Health and Human Services.

About SHM  Membership  Education  Quality Improvement  Practice Resources  Advocacy  Events  Publications
News and Media  Join SHM  SHM Store  Home  Login/Logout  Career Center  SHM Community  QI Resource Rooms  

©2007 Society of Hospital Medicine (SHM). All rights reserved.

SHM National Office: 190 North Independence Mall West, Philadelphia, PA 19106
Phone: 800.843.3360 | Fax: 215.351.2536 | Email: webmaster@hospitalmedicine.org.
Report a problem with this site.